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

 
We decided that the Plan does not have to pre-approve inpatient admission for the approved right total knee 
replacement. 
 
You asked the Plan to pre-approve inpatient admission. You say that the requested inpatient admission for the 
approved right total knee replacement is medically necessary. The Plan denied your request. The Plan says the 
requested inpatient admission for the approved right total knee replacement is not medically necessary. 
 
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 inpatient admission. Our reviewer says that the requested inpatient admission for the approved right total knee replacement is not medically necessary. 
Our physician reviewer found the knee replacement surgery may be performed safely with a 48-hour 
observational stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission for the approved right total knee replacement.
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 did not provide an argument for coverage. The Plan denied 
your request. The Plan says IRF care is not medically necessary. 
 
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 the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and acute chronic kidney injury. The patient's medical problems are stable and there are 
no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the patient has 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 this patient 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: 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 patient will lose function by going to skilled 
nursing. The Plan denied your request. The Plan says IRF care is not medically necessary and the patient can be 
managed in a skilled nursing 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. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for. a femoral blood clot and had an above the knee amputation. The patient's medical problems are 
stable and they have no complex nursing or rehabilitation needs. The patient does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the patient has 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 this 
patient 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: 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 transfer to an IRF is medically necessary for this 
enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The 
enrollee can safely receive the necessary services in an alternate 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.  
 Our physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 this 
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: 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 enrollee needs an LTACH admission. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does 
not require transfer to LTACH. 
 
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 that the record indicates that the enrollee requires ongoing acute services. The 
enrollee continues to receive acute care services, and these have not been denied. The medical record does not 
indicate that the enrollee requires services that she is not currently receiving but that would be available at the 
LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 
recommended 
 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: 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 LTACH is medically necessary for the 
patient. The Plan denied your request. The Plan says the patient can adequately receive the care needed for 
ongoing vent weaning at the current location. 
 
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 was admitted with acute respiratory failure due to pneumonia in the 
setting of recent COVID-19 infection and Guillain- Barre syndrome.  The record indicates that the enrollee 
continues to require acute care services. The enrollee continues to receive acute care services and these have 
not been denied.  The medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the labial veneer (dental code D2962) you received on 
November 11, 2021. 
 
You asked the Plan to pay for code D2962. You say that you needed a crown on your front tooth, so this 
service was necessary. The Plan denied your request. The Plan says this particular dental service is not covered 
by the Plan. 
 
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. Under the contract, only the 
following comprehensive dental services are covered: fillings and extractions, root scaling and planing, full 
mouth debridement, root canals, crowns, and bridge repairs. Labial veneers are not listed as a covered benefit. 
The code billed is not a code for a crown. 
 
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 the labial 
veneer (dental code D2962) you received on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new porcelain crown (D2740) for tooth #19. 
 
You asked the Plan to pre-approve the porcelain crown. You say that you feel that this is a necessary 
restoration. The Plan denied your request. The Plan says the records do not show that the replacement of the 
crown for #19 is reasonable at this time. 
 
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 the porcelain 
crown when the services are medically necessary and reasonable.  
 
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 porcelain crown. Our reviewer says 
that the requested crown is not shown to be reasonable and necessary in this case. Our physician reviewer 
found the one note from the provider's office indicates there is a food impaction area around tooth #19 which 
has an existing intact crown, adjacent to a distal tooth that also has a crown restoration.  The premolar mesial to 
#19 is not restored, and if the food impaction was occurring in that area a simple restoration on that tooth 
would alleviate that issue. The food trap is presumably on the distal of #19, which cannot be readily resolved unless the crown on either #19 or #18 is replaced. It is not known if there is any periodontal effect of the food 
trap. There is no obvious defect of the crown itself.   
 
As there is no decay or defect of the crown itself, and there is no documented periodontal effect of the open 
contact, there is no current necessity for the replacement of the crown on #19. Damage to the tooth around the 
crown by decay or the crown becoming unserviceable would be viable reasons for considering a new 
crown. There is no apparent damage to the tooth or crown that would necessitate the replacement of the 
existing crown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the porcelain crown have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a new porcelain crown (D2740) for tooth #19.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307 and 83789) provided on April 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be performed. 
   
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (80307 and 83789) provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis provided on December 20, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that you feel that you are being nickel and dimed out of 
your $1,000 coverage. The Plan denied your request. The Plan says you have reached your annual dental 
maximum so you will not receive a reimbursement. 
 
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, you also have a maximum benefit of 
$1,000 for covered dental services in the 2021 plan year. The Plan paid $1,000 for dental services provided on 
June 23, 2021, June 25, 2021, and August 18, 2021, which exhausted your benefit. Therefore, we decided that 
the Plan does not have to pay for the prophylaxis provided on December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing (CPT 
code(s): 81404 and 81479) provided on May 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the denial of the cardiovascular screening/risk assessment panel is administratively 
upheld for not meeting Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for cardiac risk assessment genetic screening testing (CPT code(s): 81404 
and 81479) provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and post and core buildup you received on 
December 13, 2021. 
 
You asked the Plan to pay for the crown and post and core buildup. You say that you had approval for these 
services and you would not have had them done if they weren't approved. The Plan denied your request. The 
Plan says you have exhausted your dental benefit for the year. 
 
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. Your Plan contract says that 
you are only covered for dental services up to $2000 per year.  You hit this maximum amount prior to the claim 
for the crown and post and core buildup services processing. 
 
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 the crown 
and post and core buildup you received on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on March 8, 2021. 
 
You asked the Plan to pay for the moderate sedation services (99152). The Plan denied your request. The Plan 
says the Plan says that CPT codes 93451, 76937, 99233 have been paid. The Plan also says that the records do 
not support CPT code 99152. 
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, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the moderate sedation services (99152). Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that no records were found for sedation services performed on March 8, 2021. Therefore, this procedure 
cannot be verified by the documentation provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the moderate sedation services (99152) have not been met. Therefore, we 
decided that the Plan does not have to pay for the moderate sedation services (99152) provided on March 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from October 21, 2021, 
to October 31, 2021. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
had returned to baseline and did not have skilled nursing needs. 
 
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 pay for the skilled nursing services. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily 
skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from October 21, 2021, to October 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain fused to predominantly base metal 
(D2751) provided June 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the crown. You say that neither you nor your physician were aware that the 
provider was OON in 2021. The Plan denied your request. The Plan says this service is not covered when 
provided OON. 
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. The Plan covers the crown 
when the services are provided in-network.  
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the crown have not been met. Therefore, we decided that the Plan does not have to pay for the crown - 
porcelain fused to predominantly base metal (D2751) provided June 14, 2021, by an out-of-network (OON) 
provider.