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 this level of therapy and medical monitoring cannot 
be received at a skilled nursing rehab level as they do not provide the daily frequency needed for the enrollee's 
care. The Plan denied your request. The Plan says the services the enrollees needs can be provided safely in 
another 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 enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that depression is a high-risk condition for 
hospitalization. You also say that other insurance plans offer more benefits on this matter. The Plan denied 
your request. The Plan says based on the information submitted, there is no documentation that you meet the 
criteria for coverage. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI benefits have been met. 
Specifically, medical records were not provided for this case. The records show that the Plan made multiple 
attempts to obtain this information, but it was not received. Without medical records we are unable to 
determine if you meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right thread superficial peroneal nerve release. 
 
You asked the Plan to pre-approve the procedure.. The Plan denied your request. The Plan says this 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this is an experimental/investigational procedure, and therefore, is deemed not medically 
reasonable and necessary. 
 
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 procedure. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right thread superficial peroneal nerve release.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140), intraoral - periapical first 
radiographic image (D0220) and resin-based composite - three surfaces, posterior (D2393) provided on 
November 28, 2022. 
 
You asked the Plan to pay for dental services. You say that this 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 limited oral evaluation (D0140), intraoral - periapical first radiographic image (D0220) and resin-based composite - 
three surfaces, posterior (D2393) provided on November 28, 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 the services are medically necessary for the enrollee 
to receive the proper level of care. The Plan denied your request. The Plan says the services the enrollee needs 
can be provided safely in another 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 enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), 
prophylaxis - adult (D1110), bitewings - two radiographic images (D0272), and intraoral - periapical first 
radiographic image (D0220) provided on November 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that when you retired the 
provider had changed. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), bitewings - two 
radiographic images (D0272), and intraoral - periapical first radiographic image (D0220) provided on 
November 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional 
radiographic image (D0230 x3), bitewings - four radiographic images (D0274), unspecified diagnostic 
procedure, by report (D0999), prophylaxis - adult (D1110), topical application of fluoride  excluding varnish 
(D1208), crown - porcelain/ceramic (D2740 x2), crown - porcelain/ceramic (D2950 x2), and pulp cap - indirect 
(excluding final restoration) (D3120 x2) provided on November 2, 2022, and November 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan representative provided you with the 
provider to go to. The Plan denied your request. The Plan says the dental services were received from an out-
of-network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation - new or established patient (D0150), intraoral - periapical first 
radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230 x3), bitewings - 
four radiographic images (D0274), unspecified diagnostic procedure, by report (D0999), prophylaxis - adult 
(D1110), topical application of fluoride  excluding varnish (D1208), crown - porcelain/ceramic (D2740 x2), 
crown - porcelain/ceramic (D2950 x2), and pulp cap - indirect (excluding final restoration) (D3120 x2) 
provided on November 2, 2022, and November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment services coded G2067 
provided on October 10, 2022. 
 
You asked the Plan to pay for the medication assisted treatment services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 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 G2067 is medication assisted treatment, methadone; 
weekly bundle including dispensing and/or administration, substance use counseling, individual and group 
therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment 
program). 
 
We find that CPT code G2067 is not supported in the medical record. Specifically, payment is not allowed for 
this claim because this service does not meet the opioid treatment program criteria for payment. Payment can 
only be made for opioid treatment program claims for staffing, availability and accessibility of services, care 
coordination, scope of services, quality and other reporting, and organizational authority (SAMHSA) criteria 
providers. Review of the file does not support that the provider meets this program criteria. Based on this 
information, we decided that Medicare rules for coverage of the medication assisted treatment services have 
not been met. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment 
services coded G2067 provided on October 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound screening for abdominal aortic aneurysm 
(AAA) (76706) provided on November 11, 2022. 
 
You asked the Plan to pay for the ultrasound screening. You say that it was recommended you have this done, 
and you should have it done annually. The Plan denied your request. The Plan says your maximum benefit has 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for abdominal aortic aneurysm (AAA).  
We looked at the file and Medicare rules. Specifically, the record shows that you received an ultrasound 
screening for abdominal aortic aneurysm (AAA) on December 2, 2021, and your ultrasound screening for AAA 
benefit has been exhausted. Based on this information, we decided that Medicare rules for coverage of the 
ultrasound screening have not been met. Therefore, we decided that the Plan does not have to pay for the 
ultrasound screening for abdominal aortic aneurysm (AAA) (76706) provided on November 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve the drug. You say that you have provided a statement of medical necessity. 
The Plan denied your request. The Plan says this must be supplied by a medical provider or medical facility. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a complete upper denture (D5110) and a complete lower denture 
(D5120) provided on December 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like for the dentures to be covered. 
The Plan denied your request. The Plan says that your annual dental maximum benefit for the year has already 
been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your annual dental maximum benefit for the year of 2022 was 
exhausted. Specially there was no documentation showing the Plan paid any dental services for the year prior 
to the date of service. The Plan paid $537 for the complete upper denture leaving the balance of $463 ($1,000 
annual maximum - $537 paid) left for the annual dental maximum. Therefore, we decided that the Plan has to 
pay for a complete upper denture (D5110) and a complete lower denture (D5120) provided on December 26, 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (81479) provided on April 19, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and 
reasonable. The Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan has not provided any evidence 
to support that this claim was a duplicate submission, and there is no documentation to show that this same 
service has already been paid for this date. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have been met. Therefore, we decided that the Plan has to pay for laboratory 
services (81479) provided on April 19, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. The Plan denied your request. The Plan says this 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 an ILR. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation provided to suggest a history of recent unexplained syncope, cryptogenic 
stroke, or any other apparent indication for an implantable cardiac monitor (ICM). There is insufficient 
documentation to support the medical necessity for insertion of an ICM in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service October 17, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the records do 
not support the billed code. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity.  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 billed services. Our reviewer found that 
the enrollee presented with weakness and difficulty articulating sentences. CPT code 99223 was not supported. 
This initial hospital care evaluation and management code requires a comprehensive history, a comprehensive 
examination and medical decision making of high complexity. However, the medical records submitted did not 
support a comprehensive examination and medical decision making of high complexity. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99223 billed for date of service October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office visit (99203) provided on November 
25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that you did not see a provider on this date of 
service. You also say that you do not understand why you received this denial. The Plan denied your request. 
The Plan says prior authorization was not obtained. 
 
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 provider in this case is not a network provider with the Plan. 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. The record indicates that the facility you visited was a COVID-19 testing site. Therefore, we decided that the Plan does not 
have to pay for the new patient office visit (99203) provided on November 25, 2022, by an out-of-network 
(OON) provider.