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

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 2, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 2, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric care from March 
2, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of March 2, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond March 2, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
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 psychiatric care from March 2, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 2, 
2022, forward.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (99053) provided on February 13, 2021. 
 
You asked the Plan to pay for code 99053. 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 as billed. 
 
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 looked at the file and Medicare rules. Code 99053 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the medical services (99053) provided on February 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 83789) provided on March 
16, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. CPT code 83789-59 remains not supported. This 
code has an unbundle relationship with procedure code(s) G0480; therefore, it cannot be separately reimbursed. 
Therefore, the billed code and the appended modifier cannot be verified. This code is not separately reimbursed 
when billed for specimen validity testing on urine specimens utilized for drug testing. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory service (CPT code 83789) provided on March 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services (90834) provided on March 26, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this claim needs to be submitted to a different vendor.
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 evidence as to why this service would not be covered. Per the contract with the plan and Medicare rules, behavioral health is a covered benefit. 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 psychotherapy services (90834) provided on March 26, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), cone beam computed 
tomography (CT) (D0364), retreatment of a previous root canal (D3348), and filling (D2391) provided on 
September 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that the statement given to you by the plan 
representative regarding benefit limits was very vague and misleading. The Plan denied your request. The Plan 
says there is a maximum annual benefit of $1,000 for dental services. The Plan says 1 limited oral evaluation is 
covered per plan year. The Plan says that the frequency limit for this service has been exceeded. The Plan also 
says cone beam CT is not listed as a covered service. 
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 retreatment of a previous root canal 
and filling are listed as covered, the annual maximum benefit of $1,000 has been exhausted. The record shows 
on the date of service in this case you had $328 remaining of the annual maximum benefit which was applied 
to the retreatment of a previous root canal. You are responsible for the remaining amount as well as the amount 
of the filling. The record shows that the Plan paid for a limited oral evaluation that you received on May 27, 
2021, exhausting the frequency limit of one per plan year. Additionally, cone beam CT is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140), cone beam computed tomography (CT) (D0364), retreatment of a previous root canal 
(D3348), and filling (D2391) provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - four or more surfaces, posterior 
(D2394) provided September 8, 2021. 
 
You asked the Plan to pay for the filling. You say that you thought the Plan covered more fillings. The Plan 
denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
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 two fillings 
per calendar year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a filling was covered 
on August 11, 2021, as well as one filling covered on September 8, 2021. Based on this information, we 
decided that the Plan's frequency limit for coverage of the filling has been exceeded.  Therefore, we decided that the Plan does not have to pay for the resin-based composite - four or more surfaces, posterior (D2394) provided September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110), intraoral complete series (D0210), 
and fluoride (D1206), provided on October 20, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says fluoride treatment is not listed in the Plan's benefit chart, intraoral complete 
series is limited to one every three years and cleanings are covered at 50% when received out-of-network. 
 
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 the 
prophylaxis (D1110), intraoral complete series (D0210), and fluoride (D1206), provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), comprehensive oral 
evaluation - new or established patient (D0150), and intraoral - complete series of radiographic images 
(D0210) provided November 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental cleaning, comprehensive oral exam and complete series of x-rays. You 
say that you were referred to this dentist by a plan representative. The Plan denied your request. The Plan says 
they could find no record of a phone call providing incorrect information about the provider's network status. 
These services are 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 Plans coverage rules apply in this case. The Plan covers the dental 
cleaning, comprehensive oral exam and complete series of x-rays 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 dental cleaning, comprehensive oral exam and intraoral x-rays have not been met. Therefore, we decided 
that the Plan does not have to pay for the prophylaxis - adult (D1110), comprehensive oral evaluation - new or 
established patient (D0150), and intraoral - complete series of radiographic images (D0210) provided 
November 15, 2021, by an out-of-network (OON) provider.  
 
Your complaint about potentially receiving misinformation from a plan representative is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (81479) provided on July 27, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the correct place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that 
the Plan does not have to pay for Guardant360 testing (81479) provided on July 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
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 based on the documentation provided, you 
do not have documented skilled nursing needs. In addition, you do not have documented skilled therapy needs.  
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be 
provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and additional periapical 
x-rays (D0230 x 2) provided on March 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that this charge should be voided. The Plan denied 
your request. The Plan says periapical x-rays are not listed as 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 periapical x-rays are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial 
periapical x-ray (D0220) and additional periapical x-rays (D0230 x 2) provided on March 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the shoulder for
the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says there has not been an exam of the shoulder joint or x-ray results of the shoulder, which
is required before MRI.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
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 MRI. Our reviewer says that the
requested MRI is not medically reasonable or necessary. Our physician reviewer found the record indicates that
the enrollee was seen for lumbosacral pian and an addendum to the visit a week later indicated that the enrollee
had shoulder pain after a fall six weeks previously. No examination abnormalities are noted. A plain film x-ray
demonstrates moderate osteoarthritis The record does not indicate any treatments provided. The requested
service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical
condition at this time. The elements of the coverage criteria are not satisfied.
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve magnetic resonance imaging (MRI) of the shoulder for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Maxillary Partial Denture (D5213), provided on 
September 28, 2021. 
 
You asked the Plan to pay for the Maxillary Partial Denture. You say that the service should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 the 
Maxillary Partial Denture (D5213), provided on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crowns (D2740) provided on August 
23, 2021. 
 
You asked the Plan to pay for crowns. You say that these services were necessary and should be covered. The 
Plan denied your request. The Plan says you previously met your $1,000 allowance for dental care in 2021. 
You are responsible for any amount over and above this allowance. 
 
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 provides a maximum 
$1,000 combined allowance for supplemental preventative and supplemental comprehensive dental services 
every year. You are responsible for any amount over and above the allowance amount. 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the Plan's 
$1,000 annual limit are not covered under this benefit. Documentation shows that the Plan paid $1,000 toward 
your dental care in 2021 before the date in question. Therefore, we decided that the Plan does not have to pay 
for the porcelain/ceramic crowns (D2740) provided on August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessory, expandable controller, 
(E2377) power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, 
connectors and mounting hardware (E2313) power wheelchair accessory, electronic connection between 
wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested for the enrollee. The Plan 
denied your request. The Plan says the upgraded electronics are not medically necessary as the approved power 
options come with their own switches. 
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head 
array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic 
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an 
attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the patient 
does not need to control the power options through a joystick. The enrollee's right upper extremity strength and 
function support that the patient can control any power options through their own switches. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve power wheelchair accessory, expandable controller, (E2377) power wheelchair 
accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting 
hardware (E2313) power wheelchair accessory, electronic connection between wheelchair controller and two or 
more power seating system motors (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a precision attachment (D5862). 
 
You asked the Plan to pre-approve a precision attachment. You say that you cannot afford these services. The 
Plan denied your request. The Plan says the service at issue 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 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 pre-approve a 
precision attachment (D5862).
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 rehabilitation facility is being recommended due 
to severe weakness and you need assistance with mobility. The Plan denied your request. The Plan says that an 
IRF care is not medically necessary, and your needs can be met at a lower level of care such as a skilled 
nursing facility (SNF), home health, home physical therapy, or home with outpatient therapy. 
 
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 you have not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. Your care needs can be met at a lower level of care, such as a skilled nursing 
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 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.