Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210) of tooth #'s 20, 23, 24, 25, 
26, 27, and 28. 
 
You asked the Plan to pre-approve the surgical extractions. The Plan denied your request. The Plan says the 
documentation submitted does not support the code requested extraction code, D7210. The Plan also says that 
the x-rays do not show the need for bone removal or sectioning of the tooth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the surgical 
extractions when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical extractions. Our reviewer 
says that surgical extractions (D7210) of tooth #'s 20, 23, 24, 25, 26, 27, and 28 are not medically reasonable 
and necessary. Our physician reviewer found all teeth that are being requested for removal have at least 85% of 
the coronal structure remaining, bone loss is noted at about 10 to 15 %, making the removal of the teeth that 
much easier. There is more than adequate structure remaining on all the teeth planned for removal such that 
elevation and forceps extractions would be expected. Our reviewer found that there would be no expectation 
that bone would need to be cut in order to remove any of these single rooted teeth, a requirement for the use of 
code D7210. Our physician reviewer also found that a lesser code would be more appropriate as bone removal 
would not appear to be necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the surgical extractions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve surgical extractions (D7210) of tooth #'s 20, 23, 24, 25, 26, 27, and 28.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you could 
receive care in another setting. The Plan states you could review alternate settings if requested such as skilled 
nursing facility, outpatient setting or home health care. 
 
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 review indicates that the complexity of your nursing, medical and rehabilitation 
needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy 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. 
 
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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM at 24-
hour facility in addition to the basic service (99053) provided on October 1, 2021. 
 
You asked the Plan to pay for the additional services. You say that you would like reconsideration because you 
believe these are legal charges by the physicians. The Plan denied your request. The Plan says CPT code 99053 
has a status indicator of B. 
 
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 find that CPT code 99053 is not supported in the record. Specifically, CPT code 99053 has a status 
indicator of B. This means that the payment for CPT code 99053 is always bundled into the payment for 
another service. Based on this information, we decided that Medicare rules for coverage of the additional 
services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided 
between 10:00 PM and 8:00 AM at 24-hour facility in addition to the basic service (99053) provided on 
October 1, 2021.   
Please note, the Plan has indicated that you do not have any member responsibility for the denied additional 
services. Please contact the Plan if you are being billed by the provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323 x 6). 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says there is no documentation that the enrollee has had unfavorable response to 
preferred viscosupplementation product. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Orthovisc, Synvisc or Synvisc One. The 
reviewer also found that there is no indication that the plan's required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria 
have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Specifically, the file does not indicate that the 
enrollee has tried and failed any of the preferred drugs. Therefore, we decided that the Plan does not have to 
pre-approve Euflexxa (J7323 x 6).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site 
(D4266) and bone replacement graft for ridge preservation - per site (D7953) provided October 27, 2021. 
 
You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. You say that you feel 
the claim should be paid. The Plan denied your request. The Plan says these services are not covered under 
your 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, 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 
guided tissue regeneration - resorbable barrier, per site (D4266) and bone replacement graft for ridge 
preservation - per site (D7953) provided October 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by a 
network facility from August 13, 2021, to August 14, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be 
responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay the 
correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $345 copayment for each day for days 1 to 5 for Medicare-covered hospital care.  
 
 The enrollee has been asked to pay a $345 copayment for the inpatient hospital stay. The inpatient hospital stay 
falls within the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the inpatient hospital stay provided by a network facility from August 13, 2021, to August 14, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), two gingival 
irrigations (D4921 x2), and two periodontal procedures (D4999 x2) provided on October 20, 2021. 
 
You asked the Plan to pay for the oral hygiene instructions, gingival irrigations, and periodontal procedures. 
The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. 
 
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 oral 
hygiene instructions (D1330), two gingival irrigations (D4921 x2), and two periodontal procedures (D4999 x2) 
provided on October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 review indicates that the complexity of the patient's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you could 
receive care in another setting, and they could review alternate settings if requested such as a skilled nursing 
facility, outpatient setting or home health care. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care.  Your medical conditions are stable on outpatient medications with no issues that require a physicians 
evaluation three (3) or more times per week. You do require physical therapy and occupational therapy 
services, but the medical records provided do not clarify why you require an intensive inpatient rehabilitation 
therapy program. Provided medical records do not clarify why the intensive inpatient rehabilitation therapy 
program is necessary and why therapy at a lower level of care such as in a skilled nursing facility is not 
appropriate for you. There is no documentation that supports that you require the intensive rehabilitation 
therapy program provided in an IRF. Care at the skilled nursing facility level appears to be appropriate in this 
case. 
 
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 IRF admission and services.
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) provided on October 29, 2021. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. You say that the 2D photographic images 
were necessary to obtain a pre-authorization for the crown and core buildup. The Plan denied your request. The 
Plan says this service is not a covered benefit under your dental plan. 
 
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 two 
dimensional (2D) oral/facial photographic image (D0350) provided on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4267), an interim partial 
upper denture (D5820) and a bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve guided tissue regeneration, an interim partial upper denture and a bone 
replacement graft. You say that you are in an emergency like mode, and you need to have these services 
approved and performed as soon as possible. You also say that you do not have the monetary resource to pay 
for these services. You would like the Plan to review and reconsider coverage. The Plan denied your request. 
The Plan says the requested services are not listed and therefore are not covered benefits with your Plan. 
 
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 
guided tissue regeneration (D4267), an interim partial upper denture (D5820) and a bone replacement graft for 
ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal 
implants (D6010). 
 
You asked the Plan to pre-approve the endosteal implants. The Plan denied your request. The Plan says this 
service is not covered under your benefit plan. 
 
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 
surgical placements of implant bodies: endosteal implants (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a cannula nasal (A4615) and an unlisted service (99199) provided on September 24, 2020, to October 20, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for a cannula nasal and an unlisted service. You say that you were told by the provider that he could not put in a prescription for the device, but could put in a reimbursement through the insurance company. You also say that these are medically necessary, and you thought you would be reimbursed for these. The Plan denied your request. The Plan says the provider is not under contract with the Plan and is not certified with Medicare, and the Plan found multiple Medicare supply stores less than 25 miles from your zip code.
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 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. Therefore, we decided that the Plan does not have to pay for a cannula nasal (A4615) and an unlisted service (99199) provided on September 24, 2020, to October 20, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two resin-based composites (D2391 x2) provided on 
October 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the resin-based composites. You say that this office was given to you by the 
Plan. You also say that you would like your copayments back from the provider because you were not satisfied 
with the service you received. The Plan denied your request. The Plan says resin-based composites fall under 
the comprehensive dental coverage which will require a copayment of $20 for each service. The Plan also says 
that services provided by an OON, or non-contracted provider are not provided under your benefit program. 
 
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, you are responsible for a $20 
copayment for each restorative dental service. Therefore, we decided that the Plan does not have to pay for the 
two resin-based composites (D2391 x2) provided on October 22, 2021, by an out-of-network (OON) provider.  
 
Your complaint about possibly being defrauded by the treating dental office 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the 
enrollee could receive care in another setting and the Plan could review alternate settings if requested, such as 
skilled nursing facility, outpatient setting or home health care. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees 
medical conditions are stable on outpatient medications with no issues that require a physicians evaluation 
three (3) or more times per week. The enrollee does require physical therapy services, but the medical records 
provided do not clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. 
Provided records do not explain why the intensive inpatient rehabilitation therapy program is necessary and 
why therapy at a lower level of care such as in a skilled nursing facility is not appropriate for the patient. No 
detailed records from occupational therapy are provided with regard to their needs with activities of daily 
living. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF given the enrollee's reported level of confusion. Care at the 
skilled nursing facility level appears to be appropriate in this case. 
 
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 IRF admission and services.