Persius/hicric huggingface dataset:
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 are motivated to do whatever is necessary to get 
back to your prior level of function. The Plan denied your request. The Plan says that care can be provided 
safely in a less intensive setting. 
 
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for a fall, rhabdomyolysis, and a 
urinary tract infection. Your medical problems are stable. 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 you have 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on February 25, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the drug testing rendered on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4263 and D4266) to be 
provided by a participating provider. 
 
You asked the Plan to pre-approve a guided tissue regeneration. You say that you really need this dental work. 
The Plan denied your request. The Plan says the requested dental 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 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 
guided tissue regeneration (D4263 and D4266) to be provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services (99239) provided on August 
20, 2020. 
 
You asked the Plan to pay for the hospital discharge services. You say that you originally directed this claim to 
the wrong party. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hospital discharge services was not filed until December 15, 2021. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the hospital discharge services (99239) provided 
on August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on December 17, 2021. 
 You asked the Plan to pay for the compression stockings. You say that please find the attached documents and 
reprocess the claim towards payment. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 28, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $20 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $20 copayment for an office visit.  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 an office visit provided on October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 9, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of a computed tomography (CT) scan 
provided on November 4, 2021, billed with code 71250. 
 
You asked the Plan to pay for the CT scan interpretation. You say that the records support that payment should 
be made. The Plan denied your request. The Plan says it was found that this is a duplicate claim. Another claim 
for this service was paid already. There is no evidence that two services took place. 
 
The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims are denied but may be 
appealed. 
 
In this case, the duplicate denial was appealed; however, there is no evidence to refute that this is duplicate to a 
claim that was paid for the same service. Without evidence of two services, the denial is supported. Therefore, 
we decided that the Plan does not have to pay for the interpretation of a computed tomography (CT) scan 
provided on November 4, 2021, billed with code 71250.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve the comprehensive oral evaluation. You say that you were told you could 
continue to see your long-time dentist with prior authorization. The Plan denied your request. The Plan says 
this pre-service request is a duplicate of a previously authorized 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 record shows that a comprehensive 
oral evaluation (D0150) was previously approved for pre-authorization on December 6, 2021. Therefore, we 
decided that the Plan does not have to pre-approve another comprehensive oral evaluation (D0150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by a participating 
provider. 
 
You asked the Plan to pre-approve dental services. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says services must be provided in-network. 
 
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. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pre-
approve dental services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote management billed for services provided on 
September 28, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
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, the CPT Code Manual definition of code 99457 is remote physiologic monitoring treatment 
management services, clinical staff/physician/other qualified health care professional time in a calendar month 
requiring interactive communication with the patient/caregiver during the month; first 20 minutes. 
We find that CPT code 99457 is not supported in the medical record. The records provided do not show that the 
billed service was provided to the enrollee. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
the remote management billed for services provided on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on January 12, 2022, by the out 
of network provider. 
 
You asked the Plan to pay for the dental service. You say that a piece of your crown broke off. You say that 
you were unable to get an appointment with your regular dentist for a few weeks. You say that you did not feel 
comfortable waiting that long and made an appointment with a different dentist in the same office. You also 
say that you do not understand how this provider in the same office as your regular in network dentist is out of 
network. The Plan denied your request. The Plan says services received out of network are not covered. 
 
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, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the crown (D2740) provided on January 12, 2022, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth #26. 
 
You asked the Plan to pre-approve a crown for tooth #26. You say that your teeth hurt, and you are afraid of 
not being able to eat certain things because your teeth will fall out. The Plan denied your request. The Plan says 
the x-ray does not show caries or fractures to such a degree that a crown is necessary. 
 
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 crown for 
tooth #26 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 a crown for tooth #26. Our reviewer 
says that the criteria has not been met for a crown restoration. Our physician reviewer found although there is 
noted bone loss on the provided x-ray approaching 40%, there is no clear structural damage to tooth #26. Any 
defect found on tooth #26 could be reasonably restored with a composite material.  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 a crown for tooth #26 have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 4 extractions provided on December 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dental office advised that it was all covered 
and copays would be worked out in a way that you could afford it. You also say that you are on a very limited 
income. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 maximum allowance of $1,000  has 
been exhausted. The record shows that the Plan paid $264 for services received on November 23, 2021, $116 
for services received on December 1, 2021, and $620 for services received on the date of service in this case. 
$264 + $116 + $620 = $1,000. Therefore, we decided that the Plan does not have to pay for the 4 extractions 
provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wipes, a toilet grab bar, and a home blood pressure 
monitor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 requested wipes and toilet grab bar do not serve a purpose that is primarily medical in nature. These items 
are available to the general public and would be helpful even to those who are not sick or injured.  
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
 
Therefore, we decided that the Plan does not have to pre-approve wipes, a toilet grab bar, and a home blood 
pressure monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair items. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
enrollee has adequate upper limb strength to control the power options using their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications. 
 
The file shows that a skin protection wheelchair seat cushion was requested. The approved wheelchair includes 
a captains chair. The requested seat cushion is only covered for a wheelchair with a sling/solid seat/back, and 
not a captains chair.  
 
The file shows that an expandable control system was requested. 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 requested items. Our physician reviewer found that the enrollee has a neurologic 
disorder with functional deficits.  He meets criteria for use of a power mobility device.  The requested 
accessories are not medically necessary as he does have use of his hands and can operate and control the power 
options using the switches that are included in the basic wheelchair. 
 
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 requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve wheelchair items.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge for teeth # 6, 7 and 8. 
 
You asked the Plan to pre-approve a fixed bridge. You say that you were told by your dental office to call and 
appeal. The Plan denied your request. The Plan says bridges are 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested fixed bridge is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a fixed bridge for teeth # 6, 7 and 8.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81404 and 81479) provided on 
September 17, 2021. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81404 and 81479) provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), immediate dentures 
(D5130) and extractions (D7140) provided on November 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you paid out-of-pocket for these services and 
would like to be reimbursed. The Plan denied your request. The Plan says the provider in this case does not 
accept Medicare payment. When you see a provider who has opted out of Medicare, you will not be reimbursed 
for services. 
 
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 requires 
supplemental dental care to be received from a provider who participates in Medicare. If you use a provider 
that has opted out of Medicare, you will not receive reimbursement. We looked at the file and the Plan's rules. 
The provider in this case does not participate in Original Medicare. 
Based on this information, we decided that the Plan's rules for coverage of supplemental dental services are not 
met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), 
immediate dentures (D5130) and extractions (D7140) provided on November 8, 2021.
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 reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IFF care have 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 that the patient was admitted for below the knee amputation and was transferred to inpatient rehabilitation on February 15, 2022, then discharged home on March 15. He had an outpatient lower 
extremity revascularization procedure on April 28, 2022. He has received a prosthetic and request inpatient 
rehabilitation for training in its use. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient 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 patient 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.