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

 
We decided that the Plan does not have to pay for the resin-based composite (D2335) provided on December 1, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the resin-based composite. You say that you would like this service to be paid 
because the treating provider is not OON. The Plan denied your request. The Plan says services performed by 
an OON provider are not covered because your healthcare plan does not have OON 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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the resin-based composite (D2335) provided on December 1, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review indicates that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative 
services with regular physician evaluation. Your care needs can be met 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 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 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. 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. 
 
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and 
effectively only on an inpatient basis. 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the continued SNF admission. You say that you need more time in the 
current placement of care because you have nowhere to go. The Plan denied your request. The Plan says your 
request does not meet Medicare guidelines because based on the available information, you no longer require 
skilled services and the continuation of SNF is not medically necessary. 
 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 the continued SNF admission. Our 
reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, 
and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the continued SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continued skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), implant (D6010), 
extraction (D7140), collection and application of autologous blood concentrate product (D7921), and bone 
replacement graft (D7953) provided on March 8, 2021. 
You asked the Plan to pay for the dental services. You say that you thought you would be reimbursed $1,500 
for the services. You say that you received a bill for $2,603 instead. You also say that a plan representative 
advised the services should have been covered. The Plan denied your request. The Plan says the provider in this 
case has opted out of Medicare. The Plan also says that payment cannot be made for services performed by a 
provider that has opted out of Medicare. 
 
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, dental services performed by a 
provider that hast opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the limited oral evaluation (D0140), implant (D6010), extraction 
(D7140), collection and application of autologous blood concentrate product (D7921), and bone replacement 
graft (D7953) provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instruction (D1330), guided tissue 
regeneration (D4266), osseous, osteoperiosteal, or cartilage graft (D7950), and take home drug (D9630) 
provided on September 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised by 2 plan representatives that 
implants are covered. You say that all of the visits to this provider surround 1 tooth implant. You also say that 
this has put a tremendous strain on you as a retiree. The Plan denied your request. The Plan says the services 
you received are not listed as covered. 
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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral 
hygiene instruction (D1330), guided tissue regeneration (D4266), osseous, osteoperiosteal, or cartilage graft 
(D7950), and take home drug (D9630) provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve post and core in addition to crown (D2954 x 12), 
crowns (D2750 x 18), root canal for front tooth (D3310 x 3), root canal for bicuspid tooth (D3320 x 3), and 
root canal for molar tooth (D3330 x 2) to be provided out of network. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says dental services you receive out of network are not covered. 
 
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 post and core in addition 
to a crown, crowns, and root canals are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve post and core in addition to crown (D2954 x 12), crowns (D2750 x 18), root canal for front tooth (D3310 x 3), root canal for bicuspid tooth (D3320 x 3), and root canal for molar tooth 
(D3330 x 2) to be provided out of network.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you did not know that this provider is 
out-of-network, and that it does not matter who the member sees as long as she sees a urologist. The Plan 
denied your request. The Plan says from the records they received, no medical need is shown as to why the 
enrollee cannot get this service from a provider in the Plan network. 
 
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 specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the critical care services (99291) provided on September 24, 2021. 
 
You asked the Plan to pay for the critical care services. You say that the enrollee was seen in the critical care 
unit and choosing an in-network physician was not an option for the enrollee. The Plan denied your request. 
The Plan says that there is no authorization on file for these services. 
 
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. The Plan did not provide a copy any medical records for this case. Without this 
information we cannot determine that the Plan's coverage rules support the denial of payment in this case. The 
documentation also does not state whether the hospital was in-network or out-of-network. Consequently, the 
Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay 
for the critical care services (99291) provided on September 24, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of the skilled nursing facility (SNF) 
care to be provided at a network facility. 
 
You asked the Plan to pre-approve the continuation of the SNF care. You say that you are not ready to be 
discharged due to a bladder infection as well as losing your balance when you stand. You state you do not have 
help at home. The Plan denied your request. The Plan says authorization denied because the SNF care is not medically necessary and a valid NOMNC was issued and signed on April 6, 2022, with the last covered day 
being April 8, 2022. 
 
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 the continuation of the SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no 
identifiable skilled nursing service needs that require skilled nursing services, including the specialized skill, 
knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically 
necessary and reasonable treatment. The records do not document the need for intravenous medications, new 
tube feeding, or ostomy care or daily complex wound care. There are identifiable skilled therapy service needs 
that require skilled therapy services, including the specialized skill, knowledge and judgment of a qualified 
therapist required to safely and effectively provide medically necessary and reasonable treatment. You do not 
require skilled nursing or therapy services on a daily basis. Despite daily skilled therapy in the nursing facility 
since 02/24/2022 you have made little significant progress. Part-time therapy now appears to be indicated. 
As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in 
a skilled nursing facility setting 
 
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 continuation of the SNF care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the continuation of the skilled nursing facility (SNF) care to be provided 
at a network facility.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (77520). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no compelling data to suggest that proton therapy is superior to or 
more beneficial than intensity-modulated radiation therapy or image-guided radiation therapy. The generally 
accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not 
routinely offer it to enrollees. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (77520).
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee appears to not be stable enough for 
transfer at this time. Acute care services can be safely administered at the current facility for the time being 
until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a deep brain stimulator. 
 
You asked the Plan to pre-approve a deep brain stimulator. You say that this procedure is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is not 
covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that a deep brain stimulator is not reasonable and 
necessary for patients with non-idiopathic Parkinson's disease or "Parkinson's Plus" syndromes. 
 
We looked at the file and Medicare rules. In this case, the enrollee has been diagnosed with drug-induced 
Parkinsons disease or non-idiopathic Parkinsons disease. Based on this information, we decided that 
Medicare rules for coverage of a deep brain stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the implantation of a deep brain stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyeglasses. 
 
You asked the Plan to pre-approve eyeglasses. You say that you need your eyeglasses replaced because they 
are scratched. The Plan denied your request. The Plan says services are not covered unless the plan's vision 
vendor is utilized.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve 
eyeglasses.