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

 
We decided that the Plan does not have to pre-approve dental services (D6057, D4266, D6011, D5875) 
 
You asked the Plan to pre-approve the dental services. 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 pre-approve 
dental services (D6057, D4266, D6011, D5875)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete maxillary denture (D5110) and 
mandibular partial denture (D5212) provided on March 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dentures. You say that you counted on being paid back in full when you 
wrote the check paying for these dentures. The Plan denied your request. The Plan says you are responsible for 
any charged amount above the Plans cost-sharing amount when your services are received from 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 Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the OON providers charges and the Plans payment. 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 pay more for the complete maxillary denture (D5110) and mandibular partial 
denture (D5212) provided on March 21, 2022, by an out-of-network (OON) provider.
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 physical and occupational therapy are highly 
recommended. The Plan denied your request. The Plan says the enrollee will not be able to tolerate more than 3 
hours of intense rehabilitation. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for weakness and a stroke. Her medical problems are 
stable. There is not a reasonable expectation that this enrollee will be able to fully participate in the intensive 
rehabilitation therapy program provided in an IRF. 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 pay more for the resin-based composite (D2391) on tooth #21 
provided on July 27, 2022. 
 
You asked the Plan to pay more for the resin-based composite. You say that you had to replace a filling which 
fell out, and that you have coverage for dental basic services at 50% coverage for dental fillings. The Plan 
denied your request. The Plan says your total responsibility for the filling is $88, and the claim was found to be 
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 contract says white fillings on 
posterior teeth will be processed as a silver filling and the patient is responsible for up to the contracted fee. 
The record shows that you received a resin-based composite on tooth #21, which is a posterior tooth. You are 
being charged for the less costly method, are responsible for a 50% coinsurance, plus the difference between 
the allowed amounts. Therefore, we decided that the Plan does not have to pay more for the resin-based 
composite (D2391) on tooth #21 provided on July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bioimedance Spectroscopy (BIS) assessment using the 
ImpediMed L-Dex testing device (93702 x 4). 
 
You asked the Plan to pre-approve ImpediMed L-Dex device. You say that this device is medically necessary 
for the enrollee. You say that this is needed to monitor for lymphedema post lumpectomy. You also say that the 
enrollee is at high risk of developing lymphedema. The Plan denied your request. The Plan says the requested 
device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 ImpediMed L-Dex device. Our 
reviewer says that the requested ImpediMed L-Dex device is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested device is considered experimental. 
Therefore, the reviewer found that the requested device is 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 ImpediMed L-Dex device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Bioimedance Spectroscopy (BIS) assessment using the ImpediMed L-Dex 
testing device (93702 x 4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to end-stage renal disease (ESRD) provided on April 
15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 11, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 29, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the dental services under the enrollees dental benefits. We 
decided that the Plan does not have to pre-approve the requested dental services under the enrollees medical 
benefit plan.  You asked the Plan to pre-approve the tooth extractions and dentures. You say that the dental procedures are 
necessary. The Plan says that the requested dental services are not covered under the enrollee's medical benefit. 
 
We decided that the Plan has to pre-approve the dental services under the enrollees dental benefits.  
 
The Plan follows Medicare rules. Medicare rules say that 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 EOC shows that the tooth extractions and dentures are covered under the enrollees dental benefits. Therefore, 
we decided that the Plan has to pre-approve the dental services under the enrollees dental benefits.  
 
We also decided that the Plan does not have to pre-approve the requested dental services under the 
enrollees medical benefit plan. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare generally does not cover dental services. 
Therefore, we decided that the Plan does not have to pre-approve the requested dental services under the 
enrollees medical benefit plan. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited appeal 
for this enrollee. You also say that you have submitted records. The Plan denied your request. The Plan says 
according to the information reviewed on appeal, the requested service is not medically necessary. 
 
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 there are no services at the LTACH that the patient requires that are not already 
available and covered at the current 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not ready to be discharged and would like to 
remain at the skilled nursing facility until you receive a prosthetic leg. The Plan denied your request. The Plan 
says that as of December 22, 2022, you will have reached your 100-day maximum for this benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you will have received 100 days of SNF care during the benefit period from August 19, 
2022, to December 22, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting (92310) provided on June 7, 2022. 
 
You asked the Plan to pay for the contact lens fitting. You say that you needed to change your contact lenses 
after your exam. You also say that this is a covered service. The Plan denied your request. The Plan says 
charges for this service are excluded from coverage under your plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. Although you have a $150 allowance per year for routine 
prescription eyewear, contact lens fitting is not listed as a covered service. Based on this information, we 
decided that the Plan's rules for coverage of the contact lens fitting have not been met. Therefore, we decided 
that the Plan does not have to pay for the contact lens fitting (92310) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), surgical placement 
of implant body: endosteal implant (D6010), surgical extraction (D7210), bone replacement graft for ridge 
preservation (D7953), custom fabricated abutment (D6057), and abutment supported porcelain/ceramic crown 
(D6058) provided from February 8, 2022, to June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like these services to be approved 
under your medical benefits. The Plan denied your request. The Plan says the services requested are purely 
dental in nature. The Plan also says these services are unrelated to the limited clinical indications, and are not 
eligible for coverage under the medical benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. The Plan has determined through a review of your Evidence of Coverage for the calendar year 
2021, there is no documented coverage for any enhanced dental benefits. Therefore, we decided that the Plan 
does not have to pay for the guided tissue regeneration (D4266), surgical placement of implant body: endosteal 
implant (D6010), surgical extraction (D7210), bone replacement graft for ridge preservation (D7953), custom 
fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058) provided from 
February 8, 2022, to June 7, 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 sitting in a hospital could make the 
enrollee prone to illness. The Plan denied your request. The Plan says the enrollee does not require a 25-day 
length of stay. 
 
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 was admitted to the acute care hospital with anemia and fatigue in the setting 
of an infected aortic valve and required cardiac surgery. The record indicates that the enrollee has ongoing 
acute medical issues and still requires acute care services before transitioning to a lower level of care. The 
enrollee continues to receive acute care services, and these have not been denied. The medical record does not 
indicate that the enrollee requires services that she is not currently receiving but that would be available at the 
LTACH facility. The requested service cannot be recommended. 
 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: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Entyvio. 
 
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 that the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has Crohn's disease of both 
small and large intestine without complications. The records are unclear if the enrollee has tried andf ailed the 
Plan's required drugs, Remicade, Inflectra, or Infliximab and Stelara. The records support that the required 
drugs would likely be contraindicated or less effective. The note dated June 13, 2022 has been off Stelara at 
least several months and has a flare of Crohn's. The requested Entyvio is reasonable and medically necessary at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve Entyvio.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds criteria for LTACH 
care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and 
does not require transfer to an LTACH. 
 
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 that the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that are not 
currently being provided but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. The requested service cannot be recommended. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need continued care so you will be able to 
become self-sufficient. The Plan denied your request. The Plan says the request is not medically necessary, the 
services you need can be provided safely in other settings, for example, a skilled nursing facility. 
 
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. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.