Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
August 19, 2022. 
 
You asked the Plan to pre-approve SNF care. You say that the continued admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the continued admission to a 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 SNF care. Our reviewer says that the 
continued requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found continued daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can 
be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care after August 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement socket for your prosthetic leg. 
 
You asked the Plan to pre-approve a replacement socket for your prosthetic leg. You say that this is medically 
necessary. The Plan denied your request. The Plan says that there is no medical record documentation provided 
for review that supports that you require a replacement socket. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.  
 
We looked at the file and Medicare rules. Specifically, medical records were not provided for review in this 
case. The record shows that the Plan made multiple attempts to secure medical records, without success. 
Without medical records, we cannot determine if Medicare criteria are met in this case. Based on this 
information, we decided that Medicare rules for coverage of a replacement socket for your prosthetic leg have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement socket for your 
prosthetic leg.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ophthalmology services (99214, 99204, 92250, 99213) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the Ophthalmology services. You say that this service is medically 
necessary. The Plan denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
Ophthalmology services (99214, 99204, 92250, 99213) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic antibiotic and steroid injections (D9612). 
 
You asked the Plan to pre-approve the therapeutic injection. You say that the injections are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested 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 
therapeutic antibiotic and steroid injections (D9612).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy (OT) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve OT. You say that the enrollee benefits from the in-house therapy services 
provided at the assisted living facility where she lives. The Plan denied your request. The Plan says care the 
enrollee receives from an out-of-network provider will not be covered. 
 
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 
occupational therapy (OT) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete series 
of intraoral x-rays (D0210), and full mouth scaling due to presence of generalized moderate or severe gingival 
inflammation (D4346) provided on April 14, 2022.  
 
You asked the Plan to pay for the dental services. You say that due to your negative experience with a prior 
dentist, you feel that the services should be considered this time. The Plan denied your request. The Plan says 
your benefit for the comprehensive oral exam and intraoral x-rays has already been exhausted. The Plan also 
says that the scaling procedure you received 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 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 comprehensive oral exam and intraoral x-rays was exhausted on date of service 
February 26, 2021. This means you would not be eligible for these services again until 2024. Moreover, the full 
mouth scaling procedure is not among the services covered under the Plans supplement dental benefit.  
 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a 
complete series of intraoral x-rays (D0210), and full mouth scaling due to presence of generalized moderate or 
severe gingival inflammation (D4346) provided on April 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergent inpatient services provided on December 27, 2021, 
to December 31, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for emergent inpatient services. You say that tt was not discovered that this member 
had provided the wrong insurance plan as their insurance until after the services were provided. The Plan 
denied your request. The Plan says the provider is out-of-network and authorization is required prior to an out-
of-network visit. 
 
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 emergent inpatient services provided on December 
27, 2021, to December 31, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires prolonged and 
intensive skilled services. The Plan denied your request. The Plan says the enrollee's care could continue in the 
current acute hospital. 
 
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 physician 
reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. The health plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radio graphic image (D0330) provided on April 
13, 2022. 
 
You asked the Plan to pay for the panoramic radio graphic image. You say that the services should be covered 
as you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as 
they do not fall within 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 Plan's coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
panoramic radio graphic image (D0330) provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on March 28, 
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 items or services 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 items or services was exhausted on date of service March 17, 2022. 
Therefore, we decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on 
March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by a 
participating provider on May 3, 20222. 
 
You asked the Plan to pay for intraoral imaging. You say that these services should be covered. The Plan 
denied your request. The Plan says the rendered dental services are not covered benefit. 
 
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 intraoral 
imaging (D0220 and D0230) provided by a participating provider on May 3, 20222.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary partial dentures (D5211), mandibular partial 
dentures (D5212), and sales tax (D9985) provided on June 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dentures did not fit well. The Plan denied 
your request. The Plan says maxillary partial dentures (D5211), mandibular partial dentures (D5212), and sales 
tax (D9985) are not covered by your supplemental 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 maxillary 
partial dentures (D5211), mandibular partial dentures (D5212), and sales tax (D9985) provided on June 2, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 21, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at time of implant placement (D6104), bone 
replacement grafts (D7953), guided tissue regeneration (D4266) and implant surgery (D6011). 
 
You asked the Plan to pre-approve a bone graft at time of implant placement (D6104), bone replacement grafts 
(D7953), guided tissue regeneration (D4266) and implant surgery (D6011). You say that you are appealing 
with supporting documents. The Plan denied your request. The Plan says these codes are non-covered 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 a bone graft at time of implant placement (D6104), bone replacement grafts (D7953), guided tissue regeneration 
(D4266) and implant surgery (D6011).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexlansoprazole for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee suffers from a severe case of 
gastroesophageal reflux disease with frequent heartburn symptoms. The Plan denied your request. The Plan 
says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexlansoprazole for the 
enrollee.  
 Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve wheelchair repairs 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that the Plan is denying necessary service 
on an unusable wheelchair for a man with no legs, leaving him no means of mobility and no means to care for 
himself. The Plan denied your request. The Plan says that the enrollee's current power wheelchair is outside of 
its reasonable useful lifetime. Medicare does not cover repair costs outside of the reasonable useful lifetime of 
a power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We looked at the file and Medicare rules. The wording of the manual says that the enrollee MAY elect to 
obtain a new piece of equipment if the item has been in continuous use for the equipments useful lifetime. 
There is no rule requiring a member to get a new item simply because the useful lifetime has been exceeded. 
There is also no restriction in subsection A of the rule that says that repairs are only provided during the 
reasonable useful lifetime of the item. The rule simply says that repairs are covered when medically necessary 
to make the equipment serviceable. There is no requirement in the rule that the equipment be replaced after the 
useful lifetime. The Plan also indicated that the cost of replacement is $30,000.00 and the estimated repair cost 
is $8,863.00, therefore the cost for the repairs do not exceed the cost of purchasing or renting a new chair. 
Based on this information, we decided that Medicare rules for coverage of the wheelchair repairs have been 
met. Therefore, we decided that the Plan has to pre-approve wheelchair repairs  
 
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 prefer to have the enrollee admitted to acute 
rehab because he was independent and active before coming to the hospital and wishes to return to being 
independent as quickly as possible. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for IRF and a lower level of care might be appropriate. 
 
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 is medically stable and does not need physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or 
documented. The enrollee does not need 3 hours a day, x5 days a week of therapies with multidisciplinary 
approach in an IRF. Document does not support the medical necessity due to lack of medical complexity and 
nursing needs for admission to an IRF. While the enrollee would benefit from physical therapy and 
occupational therapy, the enrollee's rehab needs can be safely provided in an alternate and low intensity setting 
such as in a skilled nursing 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63090 and 63091 billed for date of service 
March 14, 2022. 
 
You asked the Plan to pay for procedure codes 63090 and 63091. You say that separate providers performed 
these services, so they should be reprocessed for payment. The Plan denied your request. The Plan says 
payment for code 63090 is bundled into payment for code 22224. The Plan also says that 63091 is not covered 
because it is an add-on code and was not billed with an appropriate primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 63090 
is a column II code to column I code 22224. This claim has not been billed with an appropriate modifier to 
bypass the edit. In relation to code 63091, this code is an add-on code and has not been billed with an 
appropriate primary procedure code. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 63090 billed for date of service March 14, 2022.