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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF 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 you were admitted for surgical repair of a hip fracture after a fall. 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. 
 
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 an additional amount for the crown (D2740), core build up 
(D2950), and root canal (D3330) provided on December 20, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you were advised by a 
plan representative prior to the date of service that the cost for the services would be much lower. You say that 
you already paid $690. You also say that you are also being billed for another $1,436.10. 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 and the services are listed as covered, 
there are cost sharing amounts that apply. These are a contractual obligation you agreed to when you enrolled 
in the Plan's dental coverage. The record shows that when you contacted the plan, you only inquired about the 
root canal. Additionally, out of network providers may bill you for any amount greater than what the plan pays 
the provider. Therefore, we decided that the Plan does not have to pay an additional amount for the crown 
(D2740), core build up (D2950), and root canal (D3330) provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the dental services provided on January 4, 2022. 
 
You asked the Plan to further pay for the dental services. You say that you believe these services should be 
fully covered by the Plan. The Plan denied your request. The Plan says the Medicare-allowed amount has been 
fully paid. Any amount beyond this is not the Plan's responsibility. 
 
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 all fees 
beyond the maximum allowable fee schedule when you see an out-of-network dentist. 
 
The provider billed the Plan a total amount of $170. The Medicare allowed amount of these services was $100. 
Therefore, you have been correctly billed a total amount of $70. 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 further pay 
for the dental services provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited (problem-focused) dental exam provided on 
November 23, 2021, coded as D0140. 
 
You asked the Plan to pay for the limited oral exam. You say that you are hoping that the Plan will cover this 
because the exam was only done due to a filling falling out after a couple of days. You feel that this should not 
be counted against your limits in your benefit. The Plan denied your request. The Plan says you received a 
periodic exam and limited exam already for the 2021 year. This exhausted your dental benefit for oral exams. 
 
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 services provided exceed the 
benefit limits associated with your coverage. Therefore, we decided that the Plan does not have to pay for the 
limited (problem-focused) dental exam provided on November 23, 2021, coded as D0140.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on December 9, 2021, and 
December 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that there were not any endodontists with your 
plan in the area. The Plan denied your request. The Plan says the dental provider is not in your 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 file shows that you received an oral exam on December 9, 2021, and a root canal on December 20, 2021, 
by an out-of-network provider. Your plan contract says that covered dental services must be obtained by a plan 
provider.  The dental services were not pre-approved by the Plan. We found no exception which would require the Plan to 
pay for these services. Therefore, we decided that the Plan does not have to pay for the dental services provided 
on December 9, 2021, and December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV). 
 
You asked the Plan to pre-approve a POV. You say that this is medically reasonable and necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for a power operated vehicle (POV) to 
be covered, it must be shown that the beneficiarys home provides adequate access between rooms, 
maneuvering space, and surfaces for the operation of the POV that is provided. 
 
We looked at the file and Medicare rules. In this case, there is no evidence that your home has been evaluated 
to determine that there would be adequate access between rooms and maneuvering space. Based on this 
information, we decided that Medicare rules for coverage of a POV have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power operated vehicle (POV).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative would pressure therapy. 
 
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 medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that negative wound pressure therapy is covered 
when specific criteria are met. 
 
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 not medically necessary. Our physician reviewer found the enrollee has an open wound of the 
back. Imaging shows secondary malignancy mass on the spine; however, recent biopsy of the wound showed 
no sign of neoplasm although it is indirectly related to the cancer, according to the notes. Also, the negative 
wound pressure device had already been used for more than four months which is not covered by the Plan. 
Therefore, due to these two exclusionary criteria being present, the request for negative wound pressure therapy 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve negative would pressure therapy.
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. The Plan denied your request. The Plan says you do not have 
complex rehab, medical, and nursing needs. 
 
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 you were admitted to the acute care hospital for altered mental status, diabetic ketoacidosis, and 
rhabdomyolysis. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation 
needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Abilitech Assist powered arm brace. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you are 
quadriplegic. The safety and effectiveness of the requested device for your condition has not been 
demonstrated. The services are not considered reasonable or 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Abilitech Assist powered arm brace.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 22 target infectious disease panel (0242U) provided on 
July 13, 2021. 
 
You asked the Plan to pay for the 22 target infectious disease panel. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says panels of more 
than 6 targets are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 22 target infectious disease panel have not been met. Specifically, CPT code 0242U includes 22 targets. Respiratory viral panels of greater than 6 targets are non-covered. Therefore, we decided that the 
Plan does not have to pay for the 22 target infectious disease panel (0242U) provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve endodontic therapy, premolar tooth (excluding final restoration) 
(D3320) for tooth 4. 
 
You asked the Plan to pre-approve a root canal. You say that you need a root canal. The Plan denied your 
request. The Plan says that tooth #4 has lost nearly 70% of its facial bone support and gingival tissue. This 
renders the tooth with a very poor to hopeless prognosis. This condition does not meet required clinical criteria 
to establish medical necessity. 
 
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 a root canal 
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 root canal. Our reviewer says that a 
root canal for tooth #4 is medically necessary. Our physician reviewer found that a review of the 
documentation indicates that there is adequate bone support (50%) of tooth #4. Root canal treatment required to 
maintain the integrity of tooth #4 is reasonable and necessary. 
 
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 root canal have been met. Therefore, we decided that the Plan has to pre-
approve endodontic therapy, premolar tooth (excluding final restoration) (D3320) for tooth 4.  
 
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. The Plan denied your request. The Plan says the enrollee does not 
need three hours of therapy per day. 
 
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 surgical repair of a hip fracture. Her medical 
problems are stable. The enrollee does not require treatment by multiple therapies in an intensive rehabilitation 
therapy program. While she has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve the CGM supplies. You say that you currently have an active authorization 
in place for Dexcom CGM supplies but would like to switch to use guardian sensors to be compatible with your 
insulin pump. You say that you want to receive new supplies early so that you can set up an educational 
training session for the guardian sensors. The Plan denied your request. The Plan says the enrollee has a current 
supply of CGM supplies and is not eligible for new supplies until May 21, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that for equipment and supplies to be covered, they must primarily 
serve a medical purpose and not be for the convenience of a person.   
 
The items at issue in this appeal would be provided for convenience and not medical needs. The records show 
that you already have medically necessary CGM supplies. The records show that you are requesting more 
supplies early so that you can set up training. This reasoning is considered for your convenience and not 
because of a medical need. No clinical records were provided to support the medical necessity of obtaining the requested supplies at this time. Therefore, we decided that the Plan does not have to pre-approve continuous 
glucose monitor (CGM) supplies.
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 this care is medically necessary. The Plan denied 
your request. The Plan says rules for IRF 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 you are currently medically stable and do not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no rehab nursing needs identified or 
documented in the record. At the current functional level, your rehab needs can be met in lower setting such as 
in a skilled nursing facility. IRF admission is not medically necessary based on medical stability, lack of 
medical complexity, and lack of rehab nursing needs and current functional level.  
 
 
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: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for the hospice or home health care provided in enrollee's residence 
(Q5001) provided on October 21, 2019, through October 22, 2019. 
 
You asked the Plan to pay for the hospice or home health care. You say that you would like reconsideration 
because this claim was submitted timely. The Plan denied your request. The Plan says that this is not a valid 
provider type. 
 
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. Specifically, the Plan has not forwarded any evidence to support why this 
provider is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the Plan's denial has not been substantiated, so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the hospice or home health care provided in enrollee's residence (Q5001) 
provided on October 21, 2019, through October 22, 2019.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on December 14, 2021, by a 
provider who has opted-out of the Medicare program. 
 
You asked the Plan to pay for the dental services. You say that you would like this claim reprocessed as you 
unaware the provider would not accept payment from Medicare. The Plan denied your request. The Plan says 
payment cannot be made to a provider who has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on December 14, 2021, by a provider who has opted-out of the Medicare program.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional physical therapy home health visits (G0151). 
You asked the Plan to pre-approve additional physical therapy visits. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested services have not been met. 
 
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 additional physical therapy visits. Our 
reviewer says that the requested visits are not medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee does not have documented, ongoing, skilled, home health physical therapy 
needs. Following the ten approved home health physical therapy visits, the enrollee is functioning at a level 
commensurate with a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 7 additional physical therapy home health visits (G0151).