Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve prefabricated abutment  includes modification and 
placement tooth #s 18 and 19 (D6056), and abutment supported porcelain/ceramic crown tooth #s 18 
and 19 (D6058). We decided that the Plan does not have to pre-approve core buildup (D2950) for teeth #'s 20 
and 22.  
 
We decided that the Plan has to pre-approve prefabricated abutment  includes modification and 
placement tooth # 18 and 19 (D6056), abutment supported porcelain/ceramic crown tooth # 18 and 19 
(D6058).  
 
You asked the Plan to pre-approve prefabricated abutment  includes modification and placement tooth #s 18 
and 19 (D6056), abutment supported porcelain/ceramic crown tooth #s 18 and 19 (D6058), and core buildup, 
including any pins when required tooth #'s 20 and 22 (D2950). The Plan says that the services are not 
medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve prefabricated abutment  includes 
modification and placement tooth #s 18 and 19 (D6056), abutment supported porcelain/ceramic crown tooth 
#s 18 and 19 (D6058), and core buildup, including any pins when required (D2950). Our reviewer says that 
dental codes represented by D6056 and D6058 are medically necessary, and code D2950 is not medically 
necessary. Our physician reviewer found it could not be determined from the documentation provided whether 
core buildup was necessary for tooth #s 20 and 22 to retain and support the approved crowns. The implant 
abutments and abutment supported crowns for areas #18 and 19 are medically reasonable and necessary to 
provide bilateral masticatory function since there are no teeth present distal to #20.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prefabricated abutment  includes modification and placement tooth # 18 and 
19 (D6056), abutment supported porcelain/ceramic crown tooth # 18 and 19 (D6058) have been met. 
Therefore, we decided that the Plan has to pre-approve prefabricated abutment  includes modification and 
placement tooth # 18 and 19 (D6056), and abutment supported porcelain/ceramic crown tooth # 18 and 19 
(D6058).  
 
We also decided that the Plan does not have to pre-approve core buildup (D2950) for teeth #'s 20 and 22. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing codes U0004 and U0005 billed for date of service 
January 27, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing was done to make effective 
treatment decision. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on April 2, 2021, and September 17, 2021. A comparison of the claims shows these are exact duplicates. There 
is no evidence to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for lab testing codes U0004 and U0005 billed for date of service January 27, 2021.
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 is stable and suitable for 
transfer to the LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient acute care and is currently unstable for transfer to an LTACH. 
 
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 that in this case the enrollee was admitted with sepsis and acute renal failure 
secondary to sepsis from spontaneous bacterial peritonitis in the setting of cirrhosis. The record indicates that 
the enrollee remains critically ill and still requires acute care services. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that are not currently being provided but that would be available at the LTACH facility. The elements 
of the coverage rules are not satisfied. The requested service cannot be recommended. 
 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: 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 enrollee requires physical and occupational 
therapy to return to their prior level of function. You say that the enrollee is at high risk for falling and re-
injuring themselves. The Plan denied your request. The Plan says an IRF admission is not medically necessary, 
and the enrollee's needs can be met at an alternate level of 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the services are medically necessary. The Plan denied 
your request. The Plan says the enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from March 1, 
2023, forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee is still 
experiencing mental health symptoms. The Plan denied your request. The Plan says psychiatric hospitalization 
while waiting to go to a long-term care facility is not an active treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued inpatient psychiatric care. 
Our reviewer says that the service is not medically necessary from March 1, 2023, forward. Our physician 
reviewer found that based upon review the records provided, this enrollee does not meet the criteria for 
treatment in an acute inpatient mental health treatment beyond the date in question of March 1, 2023, forward 
and could have been treated in a lesser restrictive setting as there were no signs of suicidal or homicidal 
ideation, auditory or visual hallucinations and was not showing any behaviors or aggression being cooperative 
and compliant while not showing any acute threats to safety while awaiting placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric care from March 1, 2023, forward.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the thorax (71250) 
provided on July 11, 2022. 
 
You asked the Plan to pay for the CT of the thorax. The Plan denied your request. The Plan says this service is 
not authorized because screening testing is not a Medicare benefit when done without documentation of 
medical indication from the treating provider. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the CT of the thorax. Our reviewer says that 
the CT of the thorax was not medically reasonable and necessary for the enrollee. Our physician reviewer 
found the record provided is insufficient to establish the medical necessity of the requested service. The 
provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the 
requested service. Our reviewer found that the elements of the coverage criteria are not satisfied. Our physician 
reviewer also found that the requested service cannot be recommended. 
 
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 CT of the thorax have not been met. Therefore, we decided that the Plan 
does not have to pay for the computed tomography (CT) of the thorax (71250) provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary when there is no non-facet pathology per clinical assessment or radiology studies that 
could explain the source of the patients pain 
 
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 facet joint injections. Our reviewer 
says that the requested injections are not medically necessary. Our physician reviewer found records show that the patient has other probable pain generators and there is a lack of facet pathology on the provided imaging. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493, 64494).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, of the nerves innervating the 
sacroiliac joint, with image guidance (64625). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this service is considered experimental/investigational because of the wide variation in efficacy 
reported in the literature. Therefore, this request is deemed not medically reasonable and 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation, of the nerves innervating the sacroiliac joint, with image guidance 
(64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bi-level positive airway pressure (BiPAP) device 
provided on October 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that the old machine was broken. The Plan denied 
your request. The Plan says no sleep study or clinical evaluation was provided. 
 
The Plan must follow Medicare rules. Medicare rules say that positive airway pressure devices are only 
covered under certain medical indications. 
 
We looked at the file and Medicare rules. In this case, there is no evidence of a sleep test or clinical evaluation 
that indicates the device was necessary for coverage. There are no medical records to show that a BiPAP device 
was part of the enrollees treatment plan at the time the device was provided. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the bi-level positive airway pressure (BiPAP) device provided on October 1, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care after February 23, 2023. 
 
You asked the Plan to pre-approve SNF care after February 23, 2023. You say that you need additional care in 
the SNF. The Plan denied your request. The Plan says that you have used 100 days for SNF coverage. 
 
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 evidence to support that the 100-day benefit had been 
exhausted for the benefit period. As such, we cannot confirm that the denial is appropriate. Therefore, we 
decided that the Plan has to pre-approve skilled nursing facility (SNF) care after February 23, 2023.  
 
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: 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 needs LTACH care. The 
Plan denied your request. The Plan says LTACH care 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 that in this case the enrollee was admitted with postoperative complications from 
acute cholecystitis. The record indicates that the enrollee is improving but still requires acute care services 
before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that are not 
currently being provided that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. The requested service cannot be recommended. 
 
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: 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 to help the 
enrollee regain maximum function. The Plan denied your request. The Plan says they will continue to cover 
medically necessary acute and critical care at the current facility until the enrollee's condition is stable for 
transfer to an alternate level of care. 
 
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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99220 billed for date of service August 6, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the code is 
an unbundled service. 
 
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. 
 
We looked at the file and the rules. We find that code 99220 is a column I code to column II code 99217. The 
code at issue is payable with this code pair. The Plan has not provided any other Medicare ruling that indicates 
the code should not be paid. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
procedure code 99220 billed for date of service August 6, 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: 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 you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have 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 the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to 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 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.