Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is unable to feed themselves and needs 
assistance getting up. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's needs can be met in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for services provided on May 16, 2022. 
 
You asked the Plan to pay for services provided on May 16, 2022. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan has not provided an argument.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any of the requested documentation to 
support their decision. The documentation submitted does not indicate what services were billed, what services 
were denied or why they were denied. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the Plan's decision has not been substantiated so we must find in your favor. Therefore, 
we decided that the Plan has to pay for services provided on May 16, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
26, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 26, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to medical appointments. The Plan denied your request. The Plan says this request exceeds the routine 
transportation benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), prophylaxis - 
adult (D1110), and periodic oral evaluation - established patient (D0120) provided on November 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are questioning why the claim was denied 
as it was for your yearly visit. The Plan denied your request. The Plan says your benefit for the requested  
services $1,250 dollar limit was met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 21, 2022. The Plan 
made the following payments on date of service May 6, 2022  amount $118.00, and June 21, 2022  amount 
$1,132.00 ($118.00 + $1,132.00 = $1,250.00). Therefore, we decided that the Plan does not have to pay for 
bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), and periodic oral evaluation - 
established patient (D0120) provided on November 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from September 21, 
2022, to October 7, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you were not informed the enrollee 
would be charged for a private room that was medically necessary. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment for days 1 to 20 and a $170 copayment per day for days 21 to 100 for SNF care.  
 
The enrollee has been asked to pay a copayment $2,037.38 for SNF care. The total copayment is less than the 
standard amount of $2,380 ($170 per day x 14 days = $2,380) because the maximum out-of-pocket was met in 
the processing of this claim. This item/service falls within the SNF care benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for SNF care provided from September 21, 2022, to October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria was not met. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The information provided by the prescribing physician indicates that 
the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that 
Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic - porcelain/ceramic (D6245), retainer crown - 
porcelain/ceramic (D6740), core buildup, including any pins when required (D2950), limited oral evaluation - 
problem focused (D0140), intraoral -periapical first radiographic image (D0220), intraoral - periapical each 
additional radiographic image (D0230), extraction, erupted tooth requiring removal of bone and/or sectioning 
of tooth (D7210),bone replacement graft for ridge preservation (D7953)and guided tissue regeneration(D4266) 
provided on December 1, 2022. 
 
 You asked the Plan to pay for crowns, core buildup, evaluation, imaging, extraction, bone replacement and 
guided tissue regeneration. You say that these should be covered. The Plan denied your request. The Plan says 
these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pontic - 
porcelain/ceramic (D6245), retainer crown - porcelain/ceramic (D6740), core buildup, including any pins when 
required (D2950), limited oral evaluation - problem focused (D0140), intraoral -periapical first radiographic 
image (D0220), intraoral - periapical each additional radiographic image (D0230), extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth (D7210),bone replacement graft for ridge preservation 
(D7953)and guided tissue regeneration(D4266) provided on December 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 2, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the  emergency transport was not hospice 
related. The medical records provided support the need for the ambulance transport. The Plan denied your 
request. The Plan says the enrollee was enrollee in hospice on the date of service in question. This bill should 
be sent to Original Medicare. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 2, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on December 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodic oral evaluation (D0120), prophylaxis - adult 
(D1110) and panoramic radiographic image (D0330) provided on December 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for periodic oral evaluation (D0120), 
prophylaxis - adult (D1110) and panoramic radiographic image (D0330) provided on December 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says based on Medicare guidelines, the IRF services requested do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after April 
19, 2023. 
 You asked the Plan to pre-approve SNF care after April 19, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care after April 19, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after April 19, 2023, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after April 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 99285. You say that the service is separately payable. The Plan 
denied your request. The Plan says payment for code 99285 is bundled into payment for code 99220. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 In this case, we have confirmed that code 99285 is a column II code to column I code 99220 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99285 
billed for date of service October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine (J3490) provided on December 1, 2022. 
 
You asked the Plan to pay for Bupivacaine. You say that the service at issue has been billed correctly. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for Bupivacaine is included in the global surgery payment 
for the procedure (64493) provided on the same date. Based on this information, we decided that Medicare 
rules for coverage of Bupivacaine have not been met. Therefore, we decided that the Plan does not have to pay 
for Bupivacaine (J3490) provided on December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the leads (A4557) provided on September 13, 2022. 
 
You asked the Plan to pay for the leads. You say that procedure code A4557 is not inclusive to procedure code 
A4595. The Plan denied your request. The Plan says the benefit limit has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires (A4557) more often 
than every 12 months would rarely be reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the leads have not been met. The record shows that the leads were provided less than 12 months 
after the TENS device was provided. Therefore, we decided that the Plan does not have to pay for the leads 
(A4557) provided on September 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system. 
 
You asked the Plan to pre-approve the Volara system. You say that this is medically neccesary. The Plan 
denied your request. The Plan says the request for an airway clearance and lung expansion device is not 
reasonable and necessary and may in fact be harmful. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Volara system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found although provided records indicate the need for a device to assist you with the 
management of excess secretions, there is concern about the safety of the Volara system in a patient using a 
ventilator. As stated by the device manufacturer and the Food and Drug Administration, the Volara device has 
been recalled due to: "There is a potential of reduced oxygenation or pneumothorax/barotrauma to occur when 
the Volara system is used with in-line ventilator in home care environment." The health plan has suggested 
other devices that may be covered that may be more appropriate for your needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Volara system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Volara system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Perirectal Spacer: SpaceOAR Hydrogel Spacer 
(55874). 
 
You asked the Plan to pre-approve the SpaceOAR Hydrogel Spacer. You say that the service is medically 
necessary. The Plan denied your request. The Plan says member does not meet criteria for this service. 
 
The Plan follows Medicare rules. Medicare rules say that the member must be in a low or favorable risk group 
for prostate rectal spacers to be covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SpaceOAR Hydrogel Spacer. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found this member has very 
high-risk disease with possible local extension and suspected to have two possible areas of extra-capsular 
extension of his very high-risk tumor, and there is significant risk that his tumor is not organ confined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SpaceOAR Hydrogel Spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Perirectal Spacer: SpaceOAR Hydrogel Spacer (55874).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and 
panoramic radiographic image (D0330) provided on August 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay the bill for the 
provided services and would like insurance to pay for it. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes the 
requested limited oral evaluation - problem focused (D0140) but is limited to one procedure per plan year and 
panoramic radiographic image (D0330) but is limited to one procedure every three plan years. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D0140 and D0330 on June 21, 2022. Therefore, these benefits were exhausted as 
of June 21, 2022. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem 
focused (D0140) and panoramic radiographic image (D0330) provided on August 11, 2022.