Persius/hicric huggingface dataset:
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 appeal the denial of 
the authorization. The Plan denied your request. The Plan says the long-term acute care hospital (LTACH) 
services you are requesting do not meet the requirements for approval. 
 
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 patient does not require services at the LTACH that are not already available 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis 
(D1110) provided on February 10, 2022, and February 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you contacted the Plan at the beginning of the 
year and were told the treating provider is contracted with the Plan. 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. The Plan also says the call history was reviewed and you were given the information for 
another provider and facility. 
 
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 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 the comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on February 10, 2022, 
and February 14, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Injectafer. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of Iron deficiency anemia, unspecified. The documentation does not support 
that the enrollee has tried and failed Infed (iron dextran) and Venofer (iron sucrose). The documentation does 
not support that Infed (iron dextran) or Venofer (iron sucrose) would likely be less effective, and/or would 
likely have adverse effects for the enrollee 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve i-factor allograft and bone marrow aspirate. 
 
You asked the Plan to pre-approve i-factor allograft and bone marrow aspirate. You say that these procedures 
are medically reasonable and necessary. The Plan denied your request. The Plan says the requested services 
have not had their clinical value and effectiveness in the setting of spinal fusion surgery demonstrated in the 
peer-reviewed literature. 
 
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 i-factor allograft and bone marrow 
aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the i-factor allograft and bone marrow aspirate are 
experimental in spine surgery. More research needed before coverage can be approved.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of i-factor allograft and bone marrow aspirate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve i-factor allograft and bone marrow aspirate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on April 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 4, 2022. Therefore, 
we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789) provided on February 17, 2022. 
 
You asked the Plan to pay for code 83789. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the laboratory services (83789) provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full mouth scaling (D4346). 
 
You asked the Plan to pre-approve scaling. You say that this service is medically necessary. The Plan denied 
your request. The Plan says full mouth scaling (D4346) is not covered by your routine 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, 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 full 
mouth scaling (D4346).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in-network rate for the resin based filling (D2393), oral exam 
(D0120), periapical x-rays (D0220, D0230), bitewing x-rays (D0274), and prophylaxis (D1110) provided from 
January 21, 2022, to March 14, 2022, by the out-of-network provider. 
 
You asked the Plan to pay the in-network rate for the dental services. You say that the provider is in network. 
You say that the provider has two national provider identifiers (NPI). You say that one is out of network. You 
also say that this had to be corrected on a previous claim too. The Plan denied your request. The Plan says the 
claims processed correctly. The Plan also says that out-of-network providers may bill you for any amount 
greater than what the plan pays the provider.  
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 and the services are listed as covered, 
out of network providers may bill you for any amount greater than what the plan pays the provider. 
Additionally, the plan confirmed that the provider in this case only has one NPI and is out of network. 
Therefore, we decided that the Plan does not have to pay the in-network rate for the resin based filling (D2393), 
oral exam (D0120), periapical x-rays (D0220, D0230), bitewing x-rays (D0274), and prophylaxis (D1110) 
provided from January 21, 2022, to March 14, 2022, by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140), periodontal scaling and root planing 
(D4342), and localized delivery of antimicrobial agents (D4381), provided by an out-of-network provider on 
April 28, 2022. 
 
You asked the Plan to pay for dental services. You say that you were referred to this provider. You say that you 
do not know why you were referred to an out-of-network provider. The Plan denied your request. The Plan 
says this claim has been processed correctly. 
 
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, D4381 is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for localized delivery of antimicrobial agents 
(D4381). An extraction (D7140) and periodontal scaling and root planing (D4342) were processed with the 
correct out-of-network coinsurance amount, provided by an out-of-network provider on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reline maxillary partial dentures (D5760) and adding a tooth 
to an existing partial denture (D5650) provided on February 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why you are getting 
charged for these services. The Plan denied your request. The Plan says reline maxillary partial denture 
(D5760) and adding a tooth to an existing partial denture (D5650) are not covered by 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, 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 reline 
maxillary partial dentures (D5760) and adding a tooth to an existing partial denture (D5650) provided on 
February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bitewings - four radiographic images (D0274), 
prophylaxis - adult (D1110), and periodic oral evaluation - established patient (D0120) provided April 1, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that the provider did not tell you that they were 
no longer part of the Plan's network. The Plan denied your request. The Plan says dental services from an out-
of-network provider 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 Plan's coverage rules apply in this case. 
 
You are requesting 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 pre-approve the 
bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), and periodic oral evaluation - 
established patient (D0120) provided April 1, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT) (G6001).
You asked the Plan to pre-approve Image Guided Radiation Therapy. You say that the requested IGRT is
medically necessary. The Plan denied your request. The Plan says the requested procedure is unproven and 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 Image Guided Radiation Therapy. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found when treating skin cancers, there is generally not a need for IGRT unless
deep structures are being treated. Usually, IGRT is used when critical structures are abutting or near the target
that is being treated to high doses. This situation does not apply to the enrollee for which the target lesion can
be seen on the skin to assist in daily set up. Certainly, using ultrasound on a daily basis is not unreasonable, but
to bill for daily simple simulations and/or IGRT for a technology for which need has not been established by
published data or supported by consensus guidelines, many of which recommend against treatment with these
devices in general, would not be furnished in accordance with accepted standards of medical practice.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Image Guided Radiation Therapy have not been met. Therefore, we decided that
the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT) (G6001).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the alveoloplasty with extractions, 4 or more teeth 
per quadrant, (D7310) provided on February 10, 2022. 
 
You asked the Plan to reimburse you for the dental service. You say that you were made to pay for the 
extraction when it was a covered service. You say that you should not have to pay for this. You say that you 
feel you were taken advantage of. You also say that the charge for the alveoloplasty is not reasonable having 
only added a few minutes to the procedure. The Plan denied your request. The Plan says alveoloplasty with 
extraction is not listed as a covered service. 
 
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 alveoloplasty with extraction is not 
among those covered under this benefit. The record shows that the Proposed Treatment Plan indicates that this 
service would not be covered by the Plan. The Treatment Plan indicates that the subtotal in the insurance 
column is only an estimate of coverage. The record shows that you contacted the Plan on the date of service 
and were advised by a plan representative that alveoloplasty with extractions was not a covered service. 
Additionally, the record shows that the billed amount for the alveoloplasty was $498, less than the $494 that 
was pain in the office. Therefore, we decided that the Plan does not have to reimburse, nor pay, any amount for 
the alveoloplasty with extractions, 4 or more teeth per quadrant, (D7310) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
March 16, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you believe the Plan accepts 
cleanings every 6 months, and you do not understand the reason for this denial. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted. 
 
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 April 30, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on March 16, 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the medical criteria for an IRF admission 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 enrollee's rehab needs could be provided in an alternate and low intensity setting 
such as in a skilled nursing facility (SNF).  
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 resin-based composite fillings (D2393, D2392 x 3, D2330) 
provided on February 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 22, 2022. 
Therefore, we decided that the Plan does not have to pay for resin-based composite fillings (D2393, D2392 x 3, 
D2330) provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
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 the lab services provided on April 27, 2021, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair lift. 
 
You asked the Plan to pre-approve these services. You say that you need the lift to attend medical 
appointments. The Plan denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a car lift for scooter. 
 
You asked the Plan to pre-approve a car lift. You say that without the lift to transport your scooter, you are 
unable to attend events which decreases socialization. Please consider coverage for scooter lift. The Plan 
denied your request. The Plan says this item does not serve a purpose that is primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a car lift for scooter.