Persius/hicric huggingface dataset:
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 would like reconsideration because the IRF care 
is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
coverage. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the rendering physician is an in-network provider 
and all other claims have been paid without prior authorization. The Plan denied your request. The Plan says 
the rendering and referring providers are both out-of-network provider and there was no approved 
authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on October 28, 2021, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says your records do not show that you have any nursing or rehabilitation needs that can be provided 
only on an inpatient basis in a SNF. The services you require (wound care), can safely be received at a different 
setting. 
 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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on November 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you left the first dentist due to not being 
satisfied with both dentists. You say that you were not told you can only be billed for 1 visit per year. You also 
say that you need work done on your teeth. The Plan denied your request. The Plan says the claim denied 
correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on March 17, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction (D7140) provided by a participating 
provider on January 10, 2022. 
 
You asked the Plan to pay for a tooth extraction. You say that you thought the Plan would pay for at least one 
of the extractions. The Plan denied your request. The Plan says D7140 is not a covered benefit. 
 
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 a tooth 
extraction (D7140) provided by a participating provider on January 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and should only require short-term additional 
acute care hospital services that can be safely completed at the current facility until appropriate for a lower 
level of care. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous at this time. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 8, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the codes are 
bundled into other codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that codes 84479 and 84436 were billed along with code 84439. Code 84402 was billed along 
with code 84410. We find that there is a correct coding modifier indicator of 0 for the codes at issue. This 
means that codes 84479, 84436, and 84402 are not eligible for payment. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on October 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy on June 16, 2021. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you cannot afford to pay your 
part of the bill for chemotherapy due to being on social security. The Plan denied your request. The Plan says 
the coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare-covered drugs and administration from an in-network provider.  
 
You have been asked to pay $258.92, which is 20% of the allowed amount for chemotherapy. The allowed 
amount is $1,294.56 (20% x $1,294.56 = $258.92). Chemotherapy falls within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. 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 waive the coinsurance for chemotherapy on 
June 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on November 11, 2021. 
 
You asked the Plan to pay for the office visit. You say that the claim was coded correctly, and no billing errors 
were found. You say that the attached documentation should be reviewed, and the claim processed for 
payment. The Plan denied your request. The Plan says that the claim form is missing or has invalid CPT code. 
 
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. The Plan says the claim form is missing or has an invalid CPT code. The records 
show the claim form was submitted and the CPT code billed is a valid code. The Plan has not forwarded any 
other evidence or rationale to support their denial of this claim. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay for the office visit provided on November 11, 2021.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837), and psychiatric diagnosis 
(90791), provided on November 5, 2021, to November 23, 2021.  
You asked the Plan to pay for the psychotherapy and psychiatric diagnosis. You say that the service should be 
covered. The Plan denied your request. The Plan says the provider is not eligible to bill Medicare because 
provider is a Marriage & Family Therapist. A Marriage & Family Therapist is not eligible to bill Medicare for 
mental health services. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90837), and 
psychiatric diagnosis (90791), provided on November 5, 2021, to November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1830) provided on October 28, 2021. 
 
You asked the Plan to pay for the knee orthosis. You say that you would like this claim reprocessed based on 
the additional information being sent in. The Plan denied your request. The Plan says information required for 
processing was not included. 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Specifically, there is no documentation in the form of a 
receipt or other document that shows that the enrollee received the equipment. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the knee orthosis (L1830) provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230), and oral hygiene 
instructions (D1330) provided by Athena Bautista, D.D.S., on December 20, 2021. 
 
You asked the Plan to pay for intraoral imaging and oral hygiene instructions. You say that you were not given 
oral instructions other than to brush your teeth twice a day. The Plan denied your request. The Plan says the 
benefit limit for intraoral imaging has already been exhausted. The Plan says that D1330 is not a covered dental 
benefit. 
 
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. The Plan covers intraoral 
imaging once per calendar year. The Plan does not cover oral hygiene instructions. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of intraoral imaging have already been met. Oral hygiene instructions are not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230), and oral 
hygiene instructions (D1330) provided by a participating provider on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided by a 
contracted provider on January 24, 2022, to January 27, 2022. 
 
You asked the Plan to pay for a complete maxillary denture (D5110). You say that you had approval for 
dentures. The Plan denied your request. The Plan says D5110 is no longer a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 a 
complete maxillary denture (D5110) provided by a contracted provider on January 24, 2022, to January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis 
(D1110), bitewing x-rays (D0274), and periapical x-rays (D0220, D0230) provided on December 6, 2021, by 
the out of network dentist. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the enrollment guide 
states that you have a $0 copayment for in and out of network providers. You also say that you were not aware 
that going to an out of network provider would incur an additional cost to you. The Plan denied your request. 
The Plan says the member liability was applied correctly per your plan benefits and is your responsibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
out of network providers may bill you for any amount greater than what the plan pays the provider. Therefore, 
we decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis 
(D1110), bitewing x-rays (D0274), and periapical x-rays (D0220, D0230) provided on December 6, 2021, by 
the out of network dentist.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the clinical information indicates that your needs may be safely met in 
a less intensive setting. 
 
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.  
 The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for encephalopathy, hyperkalemia, 
Clostridium difficile colitis, and pneumonia. Your medical problems are stable. There are no complex nursing 
or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive 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. Our physician reviewer found that your condition does not 
meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Physical Therapy provided on November 3, 2021 to 
November 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Physical Therapy. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Physical Therapy provided on November 3, 2021 
to November 30, 2021 by an out-of-network (OON) provider.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 99053 provided on July 14, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has denied based on Medicare 
billing regulations. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the 
medical services coded 99053 provided on July 14, 2021.