Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are in constant pain. The Plan denied your 
request. The Plan says you do not need skilled nursing or rehabilitation services on a daily basis. 
 
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 services. Our physician reviewer 
found that you were admitted to an acute hospital with a diagnosis of abdominal pain and vomiting. You were 
diagnosed with acute ischemic bowel and was treated surgically. You do not have any parental medication; 
complex wound care, or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline. Therefore, an 
admission to a SNF for inpatient skilled rehab services is not medically 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain (D9110) 
provided on November 16, 2021. 
 
You asked the Plan to pay for the palliative (emergency) treatment of dental pain. You say that this was an 
emergency visit due to a fall which caused broken teeth. The Plan denied your request. The Plan says this 
service is not a covered expense under your dental plan. On November 16, 2021 you contacted the Plan and 
were given medical benefits, no dental benefits were given or discussed. The Plan also says that your provider 
contacted the Plan on November 16, 2021 to verify benefits, and was faxed a copy of your benefits. 
 
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 
palliative (emergency) treatment of dental pain (D9110) provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic image 
(D0350), comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and panoramic 
x-ray (D0330) provided on January 3, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic image, comprehensive oral evaluation, complete 
series of intraoral x-rays, and panoramic x-ray. You say that you believe these services should be covered. The 
Plan denied your request. The Plan says the 2D oral/facial photographic image is not a covered expense under 
your dental plan. The Plan also says that your benefits for the comprehensive oral evaluation, complete series 
of intraoral x-rays, and panoramic x-ray have been satisfied and frequency limitations have been exceeded. 
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, 2D oral/facial photographic image 
(D0350) is not among those covered under this benefit. The contract says that comprehensive oral evaluation 
(D0150) is limited to 1 procedure code every 3 calendar years, and full mouth or panoramic x-rays are limited 
to 1 procedure code every 5 calendar years. The record shows that you received a comprehensive oral 
evaluation (D0150) and complete series of intraoral x-rays (D0210) on September 14, 2020 and your 
comprehensive oral evaluation (D0150) and full mouth or panoramic x-rays benefits have been exhausted. 
Therefore, we decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic 
image (D0350), comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and 
panoramic x-ray (D0330) provided on January 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Latuda tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Latuda tablets.  
 
 
 Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
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 require 3 hours of intense therapy per day in 
order to regain maximum function. The Plan denied your request. The Plan says the denial of authorization for 
IRF care is correct. 
 
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 are stable and do not need rehabilitation physician supervision at least 3 times 
per week. While you may need physical and/or occupational therapy, your rehabilitation needs can be met in a 
lower intensity setting 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says Ondansetron to 
be administered at home is not covered under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.  
 
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 are not ready to go home, and you have not been 
able to do anything on your own. The Plan denied your request. The Plan says authorization denied because 
IRF is not medically necessary, and your needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
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 are medically stable and do not need close physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. There are no rehabilitation nursing needs identified or documented in the record. At the current 
level of function, you do not need 3 hours a day five days a week of IRF therapies with interdisciplinary 
management and the needs can be met in an alternate and lower setting such as in-home with services. 
 
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 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 is medically stable and does not need PM&R physician close supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. While the enrollee may benefit from physical therapy, and occupational therapy, the 
enrollee's rehab can be safely provided at a lower intensity and alternate setting such as in-home with services. 
 
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 a medical eye exam and evaluation (92004, 92014) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a medical eye exam and evaluation. You say that you were unable to get in 
with a strabismus specialist due to insurance and you have more trouble with distance and reading. You also 
say you still have double vision that is worsening when you look at distance. The Plan denied your request. The 
Plan says network providers are available. The Plan also says you do not have OON benefits. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a medical eye exam and evaluation (92004, 92014) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve femoral and sciatic nerve injections. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is a lack of clinical documentation explaining the rationale behind the request 
for these procedures. 
 
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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, the requested treatment has not been shown to be more effective for your 
medical condition than standard treatment. The requested injections are considered investigational for the 
treatment of your condition. 
 
 
 
 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve femoral and sciatic nerve injections.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visits provided from January 
6, 2022 to March 3, 2022. 
 
You asked the Plan to waive the copayment for telehealth visits. You say that you thought copayments were 
still not being charged because of COVID-19. If you knew you had to pay, you would have called your 
therapist once a month not once a week.  The Plan denied your request. The Plan says copayment 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 $30 
copayment for each Medicare-covered office visit or telehealth visit for outpatient mental health services.  
 
You have been asked to pay a total of $240 for telehealth visits ($30/visit x 8 visits = $240). The telehealth 
visits fall within the Outpatient mental health care 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 
copayment for the telehealth visits provided from January 6, 2022 to March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for level IV, surgical pathology, gross and microscopic 
examination (88305) special stain including interpretation and report (88312) provided November 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that your claim was denied in error because your 
submission does not represent a duplicate procedure, but analysis of a separate biopsy specimen consistent with 
ASGE guidelines. The Plan denied your request. The Plan says the provider did not bill as required by 
Medicare coding regulations. Payment is included in the facility claim. 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. The records show that 
the enrollee was outpatient on this date of service and the facility rendered procedure 88312 and 88305 on this 
date of service. The records also show another provider rendered service code 88312 and 88305 on the same 
date of service and place of service 22-outpatient hospital. Therefore, we decided that the Plan does not have to 
pay for level IV, surgical pathology, gross and microscopic examination (88305) special stain including 
interpretation and report (88312) provided November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge comprised of retainer crowns (D6751) 
for teeth #13 and #15 and a pontic (D6241) for tooth #14. 
 
You asked the Plan to pre-approve the dental bridge. You say that this service is necessary for you to eat 
properly. The Plan denied your request. The Plan says the criteria for a fixed bridge are not met in this case. 
 
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 
bridge when certain criteria are met. The Plan limits coverage of fixed bridges to front upper three-unit bridges 
to replace one missing upper tooth and front lower bridges up to four units to replace two adjacent lower teeth. 
 We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental bridge have not been met. Specifically, this bridge is requested to replace tooth #14, 
which is considered a posterior (back) tooth. Therefore, we decided that the Plan does not have to pre-approve 
a dental bridge comprised of retainer crowns (D6751) for teeth #13 and #15 and a pontic (D6241) for tooth 
#14.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0483) provided on October 28, 2021. 
 
You asked the Plan to pay for drug testing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the testing services that were rendered 
were not medically reasonable and necessary according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 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 drug testing services (G0483) provided 
on October 28, 2021, have been met. In this case, the Plan requested medical records to determine whether 
Medicare rules for coverage have been met. Therefore, we decided that the Plan does not have to pay for drug 
testing services (G0483) provided on October 28, 2021.
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 you can safely receive the services you need in other settings. 
 
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 revascularization of the leg and atrial fibrillation. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lovenox. 
 
You asked the Plan to pre-approve Lovenox. You say that the enrollee is on Coumadin for a history of 
pulmonary embolism. The Plan denied your request. The Plan says the enrollee's medical plan does not cover 
outpatient prescription drugs. 
 
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. The self-
administered drugs requested here are not among the types which are covered by Medicare Part B. 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 Lovenox.  
 
Benefits for Lovenox may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.