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

We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth # 10.
You asked the Plan to pre-approve core buildup (D2950). The Plan denied your request. The Plan says the
service is not a covered benefit.
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 core
buildup (D2950) for tooth # 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontics (D6245) and retainer crown (D6740).
You asked the Plan to pre-approve the pontics (D6245) and retainer crown (D6740). You say that the x-rays
revealed that the tooth had extensive decay and is non-restorable. The Plan denied your request. The Plan says
the services are not covered 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.
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 the
pontics (D6245) and retainer crown (D6740).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the endoscopy-cystoscopy procedure you
had on July 7, 2021, at an outpatient hospital facility.
You asked the Plan to reduce the copayment for the endoscopy-cystoscopy procedure. You say that you might
not have had the procedure done if you had known your copayment would be $450. You said that you usually
get charged $40. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450
copayment for outpatient surgery.
You have been asked to pay a $450 copayment for the endoscopy-cystoscopy procedure. The endoscopy-
cystoscopy procedure falls within the outpatient surgery benefit category. This means that you have been asked
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce
the copayment for the endoscopy-cystoscopy procedure you had on July 7, 2021, at an outpatient hospital
facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner (E1399).
You asked the Plan to pre-approve a recliner. You say that you need this item. The Plan denied your request.
The Plan says this is not a covered item.
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 recliner (E1399).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs help to walk. The Plan denied
your request. The Plan says the enrollee does not have skilled nursing or therapy needs that need to be provided
on a daily basis.
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 SNF services. Our physician reviewer
found that the enrollee's current level of function is at a contact guard assist level for walking using a rolling
walker, supervision for toilet transfers, independent for eating, supervision for grooming and toileting tasks,
and moderate assist for lower body dressing. The enrollee does not require skilled nursing or therapy services
of a skilled professional to provide medically necessary treatment in a SNF on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on
September 8, 2021.
You asked the Plan to waive the copayment for a spinal canal injection. You say that you were never informed
that you would owe such a high copayment and thought that this would just be considered a doctors office visit.
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the
correct 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). Your contract with the Plan clearly says that you must pay a $550
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You received a spinal canal injection on September 8, 2021, at an outpatient hospital facility. A spinal canal
injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $550
copayment.
You have been asked to pay a $550 copayment for a spinal canal injection. A spinal canal injection falls within
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers benefit category. This means that you have been asked to pay the correct amount based on your contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for a spinal canal injection provided
on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7210) for tooth # 19.
You asked the Plan to pre-approve the dental service. You say that you checked your Evidence of Coverage
and saw that you have 1 extraction per year. You also say that you do not understand how this could be denied.
The Plan denied your request. The Plan says 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 Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested extraction is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an
extraction (D7210) for tooth # 19.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on July 2,
2021.
You asked the Plan to waive the copayment for the ambulance ride. You say that you should not have to pay
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). Your contract with the Plan clearly says that you must pay a $275
copayment per one way trip for emergency and non-emergency ambulance services.
You have been asked to pay a $275 copayment for the ambulance ride. The ambulance ride falls within the
"Ambulance services" benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the
ambulance ride provided on July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of December 10,
2021.
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing this denial. The
Plan denied your request. The Plan says the denial of authorization for continued inpatient psychiatric care is
correct, because you are not aggressive and can take care of yourself so outpatient care may be appropriate
instead.
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 inpatient psychiatric care. Our reviewer
says that you do not meet the Medicare criteria for continued inpatient psychiatric care as of December 10,
2021. Our physician reviewer found it is not expected that you will improve in a reasonable period of time
beyond the date in question because you did not have homicidal or suicidal ideation noted and denied any
visual or auditory hallucinations. You were compliant with treatment and did not show any acute threats to
safety. It does not appear medically necessary for you to have treatment at the inpatient level of care rather than
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 inpatient psychiatric care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continued inpatient psychiatric care as of December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup for tooth #4, #5 and #22.
You asked the Plan to pre-approve the core buildup. You say that both crowns need to be redone since they are
splinted. You say that these will also be abutments for a partial and should be redetermined. The Plan denied
your request. The Plan says the crown for tooth #4 has been approved and the core buildup remains denied as a
non-covered benefit.
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, core buildup is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup for
tooth #4, #5 and #22.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4341) provided on June 28,
2021
You asked the Plan to pay for the dental service. You say that you were advised you needed a deep cleaning.
You say that you refused. You also say that this should be covered. The Plan denied your request. The Plan
says scaling and root planing is not listed as a covered service. The Plan also says that accurate information
was provided to you when you called to verify 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the scaling and root planing is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
scaling and root planing (D4341) provided on June 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 an IRF admission is not medically necessary.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee was admitted for peripheral vascular disease and had a below the knee amputation. Medical problems
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. While the enrollee has 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 this
enrollee 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 IRF admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that the enrollee is not a candidate for a second
steroid injection. The Plan denied your request. The Plan says that the enrollee has not tried and failed
conservative management.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Synvisc-One. Our physician reviewer
found that the enrollee has osteoarthritis of her right knee. She tried an intra-articular steroid injection which
did not provide significant relief. The request is for viscosupplementation. It is medically reasonable and
necessary to try viscosupplementation after a failed trial of steroid. Repeating the steroid is not evidence based.
Viscosupplementation has long term value for pain relief based on clinical research that appears in a CMSapproved
medical journal. The documentation does support that the requested drug is safe and effective and
otherwise reasonable and necessary for this enrollee
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc-One have been met. Therefore, we decided that the Plan has to preapprove
Synvisc-One.
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 acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found you were admitted to the hospital
for decreased appetite, confusion, and weakness.
You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. While you need 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cone beam CT capture (D0367).
You asked the Plan to pre-approve the cone beam CT capture (D0367). You say that you can lose fillings if the scan is not done, and the doctor said its necessary. The Plan denied your request. The Plan says the service is not a covered benefit.
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 the cone beam CT capture (D0367).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on June 15, 2020, through June 21, 2020 and billed at the 854 diagnosis related group (DRG) level.
You asked the Plan to pay for the inpatient hospital services with DRG 854. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the DRG billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with A41.9. 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 inpatient hospital services with DRG 854. Our reviewer says that the documentation does not support DRG 854 with a primary diagnosis of Sepsis, unspecified organism. Our physician reviewer found there is insufficient evidence from the documentation of organ failure to meet criteria for sepsis. The kidney dysfunction was not noted to be likely related to sepsis in the notes. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on June 15, 2020, through June 21, 2020 and billed at the 854 diagnosis related group (DRG) level.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88184, 88185, 88189) provided on May
20, 2021.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan
denied your request. The Plan says there is not an order for these services.
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must
be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician.
We looked at the file and Medicare rules. There is not a physician order in the file for the testing at issue.
Based on this information, we decided that Medicare rules for coverage of laboratory services have not been
met. Therefore, we decided that the Plan does not have to pay for laboratory services (88184, 88185, 88189)
provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve an endodontic therapy (D3310) for tooth # 23.
You asked the Plan to pre-approve the endodontic therapy. The Plan denied your request. The Plan says that
the dental records show that this treatment is not appropriate due to the overall poor condition of your teeth.
The Plan also says that your dental records do not show that your teeth or gums are healthy enough for this
dental work.
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
endodontic therapy 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 endodontic therapy. Our reviewer
says that the documentation meets the criteria for coverage for a root canal (D3310) for tooth # 23. Our
physician reviewer found that a root canal is reasonable and necessary to retain the tooth due to pulpal
pathology. Our reviewer also found that the bone support appears adequate (50%) for retention of the tooth.
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 endodontic therapy have been met. Therefore, we decided that the Plan has
to pre-approve an endodontic therapy (D3310) for tooth # 23.
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 lette