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 the enrollee needs this to be approved so they can get 
back to their baseline The Plan denied your request. The Plan says the enrollee can safely receive the services 
needed in another setting such as a skilled nursing facility, home with home health services 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 the enrollee does not require treatment by multiple therapies. The enrollee has had a 
decline from their baseline level of function and would likely benefit from occupational and physical therapies, 
but they do not require the intensity of therapies provided on acute inpatient rehabilitation. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies billed 
for date of service September 21, 2022. 
 
You asked the Plan to pay for the billed services. You say that the device was supplied during the enrollee's 
procedure. The Plan denied your request. The Plan says the devices are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 
 The durable medical equipment was provided in an ambulatory surgical center. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pay for the pneumatic compression device and related supplies billed for date of 
service September 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service November 
30, 2022. You asked the Plan to pay for procedure code 99284. You say that the enrollee was seen twice on the same day. 
The Plan denied your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 
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, we have confirmed that code 99284 is a column II code to column I code 99285. The code at issue 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99284 billed for date of service November 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203), Prolia injection (J0897), 
and special service, procedure, or report (99199) provided from May 25, 2022, to June 14, 2022. 
 
You asked the Plan to pay for the outpatient office visit, Prolia injection, and special service, procedure, or 
report. You say that you must get Prolia injections every 6 months for your bone loss, and you had to get an 
injection while you were spending time in Canada. You also say that you do not believe covering this expense 
would have been any more expensive to the Plan than if the injection had been given in the United States. The 
Plan denied your request. The Plan says while in Canada, you saw a provider and had Prolia injection given. 
The Plan also says this was not an emergency situation because you receive Prolia every 6 months. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage except for the services listed in the Medicare rules section of this letter, and 
certain services rendered on board a ship. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient office visit, Prolia injection, and special service, procedure, or report have not been 
met. Specifically, these services were not provided on an emergency basis, and non-emergency care is not 
covered outside of the U.S. and the U.S. territories. Therefore, we decided that the Plan does not have to pay 
for the outpatient office visit (99203), Prolia injection (J0897), and special service, procedure, or report (99199) 
provided from May 25, 2022, to June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77080 billed for date of service October 3, 
2022. 
 
You asked the Plan to pay for procedure code 77080. You say that the claim should be paid as billed. The Plan 
denied your request. The Plan says payment for code 77080 is bundled into payment for code 77085. 
 
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, we have confirmed that code 77080 
is a column II code to column I code 77085 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 77080 billed for date of service October 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex device placement surgery. 
 
You asked the Plan to pre-approve the vertiflex device placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 vertiflex device placement surgery. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered experimental. 
 
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 vertiflex device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertiflex device placement surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertiflex device placement surgery (22869). 
 
You asked the Plan to pre-approve a vertiflex device. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this is considered experimental. 
 
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 a vertiflex device. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this service is considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a vertiflex device placement surgery (22869).
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 enrollee will receive appropriate level of care in 
the acute rehabilitation setting and has actively participated in all therapeutic modalities and demonstrated the 
ability to tolerate an acute rehab program's intensity. The Plan denied your request. The Plan says the enrollee's 
records do not show the need and are able to take part in 3 hours of therapy a day at least 5 days a week or 15 
hours per week, services needed can be provided safely in other settings, a skilled nursing facility, home with 
home health services 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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 has already tried and failed 
at a lower level of care multiple times. The enrollee requires daily services and would benefit from the LTACH 
level of care. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the 
current setting. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 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 a limited oral evaluation, bitewing x-ray, and application of 
caries arresting medicament (D0140, D0272, D1354) provided on June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. Coverage for the application of caries arresting medicament denied correctly as it does 
not fall within your dental 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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 8, 2022 (D0272, 
D0140) and July 6, 2022 (D0140). Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation, bitewing x-ray, and application of caries arresting medicament (D0140, D0272, D1354) provided 
on June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (AWV) provided on December 19, 
2022. 
 
You asked the Plan to pay for the AWV. You say that you assumed this service was free. You also say that you 
had to cancel your previous visit because of another appointment. The Plan denied your request. The Plan says 
the benefit for this service has been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) provided on 
December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam (92014) and fundus photography 
(92250) provided on October 21, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam and fundus photography. You say that you would like this 
claim to be reprocessed for payment. The Plan denied your request. The Plan says the enrollee chose an OON 
provider, and did not obtain a referral or authorization of rendered services. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical eye exam (92014) and fundus 
photography (92250) provided on October 21, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that this procedure is considered safe and effective. The 
Plan denied your request. The Plan says there are not enouh studies showing that Vertiflex is safe and effective. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty to allow access for 
restorative procedure, per tooth #11 (D4212) provided on June 27, 2022. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty procedure tooth #11. You say that you have 
an autoimmune disorder that affects the health of your teeth which makes it crucial to save your remaining 
teeth. The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 
gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth #11 (D4212) provided on 
June 27, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the medication assisted treatment, methadone, (G2067) provided 
on November 14, 2022. 
 
You asked the Plan to pre-approve the outpatient service. You say that the provider is certified by Substance 
Abuse and Mental Health Service Administration (SAMHSA). You also say that this should be reprocessed 
and paid. The Plan denied your request. The Plan says that this claim because it does not meet the opioid 
treatment program criteria for payment. 
 
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's rationale is not supported. The rules that the Plan cited do 
not appear to prohibit payment to the program if the prescribing physician is listed on the claim. Therefore, we 
decided that the Plan has to pre-approve the medication assisted treatment, methadone, (G2067) provided on 
November 14, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices billed for date of service 
October 14, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was for use during surgery. The 
Plan denied your request. The Plan says the devices are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 
 The durable medical equipment at issue was provided during services in an ambulatory surgical center. 
Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression devices billed for date 
of service October 14, 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 necessary, and you could benefit 
from the therapy services. The Plan denied your request. The Plan says ongoing skilled care can be provided in 
an alternative 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 you do 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 maxillary and mandibular complete dentures (D5110, 
D5120) provided on July 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 maxillary and mandibular complete dentures (D5110, D5120) provided on July 20, 2022.