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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve skilled nursing facility (SNF) care. You say that you would like to appeal 
the denial of the claim. The Plan denied your request. The Plan says the service 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 skilled nursing facility (SNF) care. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found There are no 
identifiable skilled therapy service needs for the enrollee to be admitted for SNF 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 skilled nursing facility (SNF) care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis provided on February 15, 2022. 
 
You asked the Plan to pay for prophylaxis. You say that you did not know the provider was out-of-network. 
The Plan denied your request. The Plan says the provider who performed these services is not in-network and 
therefore, not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, coverage only applies if you use a Plan 
provider. The records show you did not receive these services from a Plan provider. Therefore, we decided that 
the Plan does not have to pay for prophylaxis-adult (code D1110) provided on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and the periodic oral evaluation 
(D0120) provided on December 15, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exceeded the allowable dental 
benefit for the 2021 calendar year. 
 
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.   
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the Plan contract states that you have a $1,000 
dental allowance for the 2021 calendar year. You previously received dental services on May 5, 2021, May 21, 
2021, and June 4, 2021 in which the Plan issued payment in the amount of $1,000 for these services. Therefore, 
you have exceeded the allowable benefit for dental services.  You are responsible to pay 100% of the charges 
beyond the $1,000 dental allowance. Therefore, we decided that the Plan does not have to pay for the dental 
cleaning (D1110) and the periodic oral evaluation (D0120) provided on December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on May 11, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says there was no evidence of an 
established relationship between the member and the ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the genetic testing services provided 
on May 11, 2021, have been met. In this case, no medical documentation has been received from the ordering 
provider. Without clinical records detailing the enrollees condition, the medical necessity of the ordered 
testing cannot be reviewed. Therefore, we decided that the Plan does not have to pay for the genetic testing 
services provided on May 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) home health physical therapy visits. 
 
You asked the Plan to pre-approve home health physical therapy visits. You say that the services are necessary. 
The Plan denied your request. The Plan says the current formal therapy should meet clinical expectations with 
the now total of (20) approved visits.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapy visits. 
Our physician reviewer found the documentation does not support that the enrollee requires additional skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional 
rehabilitation services to effectively provide treatment, care, and/or services in order to improve the enrollee's 
condition, perform a maintenance program to maintain the enrollees condition and/or prevent deterioration. 
The enrollee has been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The requested home health services are not medically 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 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve five (5) home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81275, 81276, 81301) 
provided on July 8, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(81206, 81275, 81276, 81301) provided on July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on February 11, 
2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the medical documentation does not 
support payment for the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the medical records do not indicate the ordering provider discussed the medical need 
for the ordered equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
lumbar-sacral orthosis (L0650) provided on February 11, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility, at home with home health services or at home with outpatient 
therapy. 
 
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 there is not a reasonable expectation that the 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 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 the unspecified preventive procedure (code D1999). 
 You asked the Plan to pay for the unspecified preventive procedure (code D1999). You say that you were told 
services would be covered. The Plan denied your request. The Plan says this service is not covered by the 
Plan's 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 the 
unspecified preventive procedure (code D1999) provided on February 14, 2022.
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 has been treated for COVID 
19 and has lasting effects because of this. He now has a tracheostomy in place and is ventilator dependent. At 
this time, he is ready to transition to the LTACH closest to his home and family. The Plan denied your request. 
The Plan says based on Medicare guidelines, the Long-Term Acute Care Hospital (LTACH) services you 
and/or your provider 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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. 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 pre-approve the scaling in moderate or severe gingival inflammation 
(D4346). 
 
You asked the Plan to pre-approve scaling. You say that these services are medically necessary. The Plan 
denied your request. The Plan says scaling in moderate or severe gingival inflammation (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 the 
scaling in moderate or severe gingival inflammation (D4346).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services (81406, 81162, 81479). 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says that confirmation was made with 
the office of the ordering provide that the genetic testing in question was not ordered. 
 
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. In this case, the Plan has not fully substantiated their denial. Although the Plan 
has apparently confirmed that a phone call was made to the ordering provider indicating that the genetic testing 
was not ordered, there is no evidence of this in the documentation submitted. Without any direct evidence that 
this testing was not ordered, we have no indication that the signed test requisition form is somehow not valid.  
Therefore, we decided that the Plan has to pay for the genetic testing services (81406, 81162, 81479).  
 
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 currently meet IRF admission criteria under 
Centers for Medicare and Medicaid Services (CMS) guidelines. The Plan denied your request. The Plan says 
authorization denied because the IRF care is not medically necessary, and your needs can be met at a lower 
level of care such as a skilled nursing facility (SNF). 
 
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 your medical problems are stable, and there are 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 the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
 
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 retainer crowns for teeth #'s 6 and 10 (D6751), pontics 
for teeth #'s 7, 8, and 9 (D6241), and osseous surgery for all four quadrants (D4260) to be provided by a 
network provider. 
 
You asked the Plan to pre-approve the retainer crowns for teeth #'s 6 and 10 (D6751), pontics for teeth #'s 7, 8, 
and 9 (D6241). You say that you were told that implants and bridges were covered. You say it took a while to 
find a dentist to take their insurance and thought they would be covered. The Plan denied your request. The 
Plan says authorization denied because the retainer crowns for teeth #'s 6 and 10 (D6751), pontics for teeth #'s 
7, 8, and 9 (D6241) do not meet criteria and the osseous surgery on all four quadrants is not 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. The Plan covers the retainer 
crowns for teeth #'s 6 and 10 (D6751), pontics for teeth #'s 7, 8, and 9 (D6241) 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 retainer crowns for teeth #'s 6 and 
10 (D6751), pontics for teeth #'s 7, 8, and 9 (D6241). Our reviewer says that the services are not medically 
necessary. Our physician reviewer found that given the Plan's limitations on providing the fixed bridgework, 
and the lack of any contraindications to the use of a removable appliance by the member, there would be no 
necessity for the requested procedures. 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 retainer crowns for teeth #'s 6 
and 10 (D6751), pontics for teeth #'s 7, 8, and 9 (D6241) have not been met 
 
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 osseous surgery for all four 
quadrants (D4260) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve the osseous surgery for all four quadrants (D4260). Therefore, we decided that the Plan 
does not have to pre-approve retainer crowns for teeth #'s 6 and 10 (D6751), pontics for teeth #'s 7, 8, and 9 
(D6241), and osseous surgery for all four quadrants (D4260) to be provided by a network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam (CT) image capture with field of view of one 
full dental arch - maxilla, with or without cranium (D0382) provided December 14, 2021, and the surgical 
placement of mini implants (D6013) provided December 27, 2021. 
 
You asked the Plan to pay for the cone beam CT scan and mini implants. You say that you would like these 
claims to be paid. The Plan denied your request. The Plan says the claims have been reprocessed however your 
have exceeded your dental allowance. You are responsible for the costs above the dental allowance. 
 
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 cone 
beam CT scan and mini implants up to $750 every year.  
 We looked at the file, and Medicare rules. The Plan has reprocessed these claims. At the time of processing, you 
had $660 remaining in your dental allowance. This amount was applied to your claims. You have been asked to 
pay the remaining amount above the dental allowance. This means you have been asked to pay the correct 
amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the 
cone beam (CT) image capture with field of view of one full dental arch - maxilla, with or without cranium 
(D0382) provided December 14, 2021, and the surgical placement of mini implants (D6013) provided 
December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on June 15, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on June 15, 2021.