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

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 23, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have been on a 4-month schedule for dental 
cleanings since 2010 due your medical history. You say that you do not always maintain the schedule. You also 
say that 2021 allotted you to be on that time schedule. The Plan denied your request. The Plan says 2 
prophylaxis procedures are covered per plan year. The Plan also says that the frequency limit has been 
exceeded. 
 
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 and 2 prophylaxis procedures are 
covered per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for 
prophylaxis procedures that you received on February 23, 2021, and July 27, 2021. Therefore, we decided that 
the Plan does not have to pay for the prophylaxis (D1110) provided on November 23, 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 you need inpatient therapy because you need to get 
to baseline of using toilet, walking, and the basics of life. 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) care. 
 
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 you are medically stable and do not need close physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. There are no rehabilitation nursing needs identified or documented in the record. 
 
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 dental services (D5899, D5110) provided November 26, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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, code D5899 is not listed as a covered 
service. The enrollee's $2,000 annual maximum was met so the denture (D5110) cannot be fully covered. 
Therefore, we decided that the Plan does not have to pay for dental services (D5899, D5110) provided 
November 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), periapical x-
rays (D0220, D0230), and bitewing x-ray (D0274) provided on February 3, 2022, by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that you were told that everything would be the 
same as your old plan when you signed on. You say that nothing was mentioned about having to have certain 
doctors or dentist. The Plan denied your request. The Plan says there is no coverage for service when received 
by an out of network provider. 
 
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 dental services you received from an out of network provider are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the oral exam (D0120), prophylaxis (D1110), periapical x-rays (D0220, D0230), and 
bitewing x-ray (D0274) provided on February 3, 2022, by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stance control for prosthesis. 
 
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 item is included in the approved prosthesis. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The requested stance system is included in the approved prosthesis. The requested stance system cannot be 
approved separately. Therefore, we decided that the Plan does not have to pre-approve a stance control for 
prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4) 
and a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the scalings and planings and partial denture. You say that the enrollee 
needs scalings and root planings, and also needs teeth extracted for the upper partial denture. The Plan denied 
your request. The Plan says these services are not covered under your benefit plan. 
 
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 four 
periodontal scalings and root planings (D4341 x4) and a maxillary partial denture (D5213).
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 the enrollee is a stroke patient and will continue to 
lose function the longer he waits for therapy. The Plan denied your request. The Plan says authorization denied 
because the IRF care is not medically necessary, and the enrollee's 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 the enrollee is medically stable and does not need close physician supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. There are no rehabilitation nursing needs identified or documented in the record. 
 
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 fully pay for the prophylaxis and periodic oral evaluation provided 
on January 3, 2022. 
 
You asked the Plan to fully pay for the prophylaxis and periodic oral evaluation. You say that the website says 
preventive care is 100% covered and the claim should be covered. The Plan denied your request. The Plan says 
the out-of-network dental services were paid at the in-network rate as an exception. 
 
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 Plan is only obligated to pay the 
allowed amount for the prophylaxis and periodic oral evaluation. You are responsible for all differences 
between the allowed amount and the amount billed by the out-of-network dentist. Therefore, we decided that 
the Plan does not have to fully pay for the prophylaxis and periodic oral evaluation provided on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular cancer genomics (CGx) testing (CPT code(s): 
81408, 81292, 81321, and 81407) provided on October 18, 2021.  
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or 
more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one 
CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for 
molecular cancer genomics (CGx) testing (CPT code(s): 81408, 81292, 81321, and 81407) provided on 
October 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee is not ready 
for discharge and is at high risk. The Plan denied your request. The Plan says that the records received show 
the enrollee's condition has improved and she is no longer a threat to herself or others. 
 
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 hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected the enrollee would improve in a reasonable period of time as does did not have suicidal or 
homicidal ideation, auditory or visual hallucinations. The patient was compliant with treatment while not 
showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care as she does not have 
dangerousness to self or others and was compliant with her treatment. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 20, 
2022. 
 
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, and this was an annual wellness visit. The Plan denied your request. The Plan 
says the cost-sharing applied correctly based on the services provided, your last annual visit was on July 19, 
2021 and these services were considered a 6-month follow-up. 
 
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 $5 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $5 copayment for the 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 January 20, 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care. While the enrollee may benefit from physical and occupational therapy, his rehab needs can be addressed at a low 
intensity alternate setting such as in a skilled nursing facility or in-home with 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 SSBCI. 
 
You asked the Plan to pre-approve SSBCI. The Plan denied your request. The Plan says per the attestation 
submitted by the provider, the member does not have a need for intensive case management, is a high risk for 
hospitalization with diagnosis of diabetes; therefore, member does not meet the requirements for the SSBCI 
program. 
 
The Plan contract covers Special Supplemental Benefits for the Chronically Ill. The Plan says that all SSBCI 
benefits recipients must have one or more chronic condition that is life threatening or significantly limits health 
or function, be at high risk for hospitalization (clinical criteria), require intensive care coordination (care 
management). If you meet certain clinical criteria and are under care management for a qualifying chronic 
condition, you may be eligible for special supplemental benefits for the chronically ill. 
 
 We looked at the file and the Plans rules. The file shows that the attestation from your physician does not list a 
need for Intensive Care Management, which is one of the requirements for coverage of SSBCI. Based on this 
information, we decided that Medicare rules for coverage of SSBCI have not been met. Therefore, we decided 
that the Plan does not have to pre-approve SSBCI.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Chemodenervation services (64612,95874, 
J3490) provided on November 10, 2021. 
 
You asked the Plan to waive the copayment for the Chemodenervation services. 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 $300 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 You have been asked to pay a $300 copayment for Chemodenervation services. Chemodenervation services fall 
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 Chemodenervation 
services (64612,95874, J3490) provided on November 10, 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 the enrollee meets full IRF criteria. You say that the 
enrollee is willing and able to participate in an intensive rehabilitation program in hopes of regaining lost 
function and returning to the assisted living facility environment to live as independently as possible. The Plan 
denied your request. The Plan says authorization denied because the IRF care is not medically necessary, and 
the enrollee's 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 the enrollee is medically stable and does not need close physician supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. There are no rehabilitation nursing needs identified or documented in the record. 
 
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 periodontal maintenance (D4910) provided on November 
30, 2021. 
 
You asked the Plan to pay for the dental service. You say that you want this to be covered. The Plan denied 
your request. The Plan says coverage for periodontal maintenance is limited to 3 times per plan year. The Plan 
also says that the frequency limit has been exceeded. 
 
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 and periodontal maintenance is covered 
3 times per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for 
periodontal maintenance that you received on February 2, 2021, May 7, 2021, and August 27, 2021.  
Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on 
November 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services beginning April 18, 2022, for 
the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the enrollee is medically stable for discharge to 
home or a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The patient has Parkinson's Disease and was admitted to observation status with agitation and confusion, worsening over time. 
The initial evaluation did not reveal any focal deficits, poor coordination, or changes in vision. Two days later 
she was moved to inpatient status. She appears to be experiencing gradual worsening of Parkinson's dementia 
and was not found to have an acute condition requiring inpatient treatment. Although coordination of outpatient 
care was needed, documentation described the patient as not requiring hospital services that would likely cross 
2 midnights. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services beginning April 18, 2022, for the enrollee.