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 the enrollee is currently inpatient and no longer 
needs acute medical care. You also say that the enrollee is ready to transfer to rehabilitation. The Plan denied 
your request. The Plan says the criteria for admission to the Acute Inpatient Rehabilitation setting 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 the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Our reviewer also found that the enrollees care needs can be met at 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency office visit charge for services provided on 
November 16, 2021, billed with code 99058. 
You asked the Plan to pay for the services as billed. You say that this claim should be paid. The Plan denied 
your request. The Plan says payment was approved for all services except for code 99058 which is not 
separately paid by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99058 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99058 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
emergency office visit charge for services provided on November 16, 2021, billed with code 99058.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D51100 and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve dentures. You say that your current dentures are causing problems and need 
to be replaced. The Plan denied your request. The Plan says you previously received a complete upper denture 
(D5110) and partial lower denture (D5214) on December 14, 2018, which were covered by the Plan. These 
services are covered only once every five plan years. 
 
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 can cover one 
complete upper denture (D5110) every five plan years and one partial lower denture (D5214) every five plan 
years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation shows that these 
dentures are requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a complete upper denture (D51100 and partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 interim crowns (D2799 x9), a labial veneer (D2962), 2 
gingivectomies or gingivoplasties (D4211 x2), 3 pontics (D6245 x3), 4 retainer crowns (D6740 x4), and 
crowns (D2740) for tooth #'s 17 and 27. 
 
You asked the Plan to pre-approve the interim crowns, labial veneer, gingivectomies or gingivoplasties, 
pontics, retainer crowns, and crowns. You say that you need teeth to chew, talk, have less mouth pain, and can 
keep up with your oral health. The Plan denied your request. The Plan says the interim crowns, labial veneer, 
gingivectomies or gingivoplasties, pontics, and retainer crowns are not covered under your benefit package. 
The Plan also says that the request for the crowns exceeds the maximum count allowed per period. 
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, interim crown (D2799), labial veneer 
(D2962), gingivectomy or gingivoplasty (D4211), pontic (D6245), and retainer crown (D6740) are not among 
those covered under this benefit. The contract says that you are limited to no more than 4 crowns per calendar 
year, with no more than 2 crowns per arch. The record shows that you have been approved for crowns for tooth 
#'s 2, 10, 28, and 29 and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve 9 interim crowns (D2799 x9), a labial veneer (D2962), 2 gingivectomies or gingivoplasties 
(D4211 x2), 3 pontics (D6245 x3), 4 retainer crowns (D6740 x4), and crowns (D2740) for tooth #'s 17 and 27.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve 3D rendering with interpretation services (76377). 
 
You asked the Plan to pre-approve 3D rendering with interpretation services. You say that this imaging is 
medically reasonable and necessary. The Plan denied your request. The Plan says that although the MRI of the 
pelvis is approved, the 3D interpretation services are not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 3D rendering with interpretation 
services. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found in comparison with conventional multiplanar 2D turbo 
spin-echo magnetic resonance imaging (MRI) scan of the prostate, 3D T2-weighted SPACE MRI was 
associated with substantial time saving (nearly 8 minutes), had similar image quality and accuracy in the 
diagnosis of tumor and extracapsular extension, and had better tumor conspicuity. The requested 3D imaging 
service is medically reasonable and 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 3D rendering with interpretation services have been met. Therefore, we decided 
that the Plan has to pre-approve 3D rendering with interpretation services (76377).  
 
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 pre-approve a complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve complete dentures. You say that dentures are necessary. The Plan denied 
your request. The Plan says prosthodontic services (dentures) are not covered by your dental benefit. 
 
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 
complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6010) for teeth #3 and #5. 
 
You asked the Plan to pre-approve dental implants. You say that these services are necessary for you to receive 
a partial denture. The Plan denied your request. The Plan says these services are not covered by your dental 
benefit. 
 
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 
dental implants (D6010) for teeth #3 and #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 9. 
 
You asked the Plan to pre-approve the dental service. You say that a new crown is required due to a severe 
carious lesion. You say that upon removal of the caries, new build up and crown was necessary to restore the 
tooth. The Plan denied your request. The Plan says core build up is covered once per tooth every 5 plan years. 
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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and core build up is covered once per 
tooth every 5 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for core 
build up for tooth # 9 that you received on February 25, 2019. Therefore, we decided that the Plan does not 
have to pre-approve core build up (D2950) for tooth # 9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010 x 7), prefabricated 
abutments (D6056 x 7), and implant supported crowns (D6065 x 7). 
 
You asked the Plan to pre-approve the dental services. You say that you want to change your insurance if these 
are not covered. The Plan denied your request. The Plan says the requested services 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implants and related 
services are specifically excluded under this benefit. Therefore, we decided that the Plan does not have to pre-
approve endosteal implants (D6010 x 7), prefabricated abutments (D6056 x 7), and implant supported crowns 
(D6065 x 7).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 9, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth #31. 
 
You asked the Plan to pre-approve a crown. You say that this service is necessary to save your tooth. The Plan 
denied your request. The Plan says this service is not covered by your dental benefit. 
 
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 
porcelain/ceramic crown (D2740) for tooth #31.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services of more than 30 
minutes (99239). 
 
You asked the Plan to pay for hospital discharge day management services of more than 30 minutes. You say 
that you would like this claim reprocessed and approved for payment based on the medical records. The Plan 
denied your request. The Plan says the documentation does not support the services 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. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not 
document more than 30 minutes having been spent on hospital discharge day management services. Based on 
this information, we decided that Medicare rules for coverage of hospital discharge day management services  
of more than 30 minutes have not been met. Therefore, we decided that the Plan does not have to pay for 
hospital discharge day management services of more than 30 minutes (99239).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral exam (D0150) and fifteen surgical 
extractions (D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve services to be performed by an oral surgeon. You say that this denial is 
incorrect, and you were referred for these services by your dentist. The removal of these teeth is necessary to 
prevent necrosis from spreading to your jaw. The Plan denied your request. The Plan says services performed 
by an oral surgeon are not covered by your dental benefit. 
 
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 dental 
services be performed by a participating general dentist. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services performed by a dental 
specialist, such as an oral surgeon, are not among those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral exam (D0150) and fifteen surgical extractions (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010 x 10), implant supported 
crowns (D6065 x 10), and prefabricated abutments (D6056 x 10). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says dental implants and all associated services 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implants, implants 
supported crowns, and prefabricated abutments are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve endosteal implants (D6010 x 10), implant supported crowns 
(D6065 x 10), and prefabricated abutments (D6056 x 10).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home Health Services provided on September 11, 2021 to 
October 7, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Home Health Services. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Home Health Services provided on September 11, 
2021 to October 7, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that the requested item is medically necessary. The 
Plan denied your request. The Plan says the requested denture is not a covered dental item. 
 
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 complete upper denture 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a complete upper denture (D5110).
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 allowing the enrollee to transition to an 
LTAC is very beneficial. The Plan denied your request. The Plan says the criteria for an admission to an 
LTACH is not met. 
 
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 is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. Our reviewer found that the enrollee can remain at the 
current ACH until such time no acute services are required.  Our physician reviewer also found that the 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and root canal 
(D3331) to be provided by an endodontist. 
 
You asked the Plan to pre-approve the dental services. You say that your dentist has referred you to an 
endodontist for these services. You say that multiple people have advised your authorization request would be 
approved. You also say that you are in excruciating pain. The Plan denied your request. The Plan says services 
to be obtained from an endodontist 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, services to be obtained from an 
endodontist are not covered. The Evidence of Coverage clearly states that services must be performed by a 
participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive 
oral evaluation (D0150) and root canal (D3331) to be provided by an endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper and lower dentures (D5110, D5120). 
 
You asked the Plan to pre-approve complete dentures. You say that these dentures are necessary. The Plan 
denied your request. The Plan says prosthodontic services (dentures) are not covered by your dental benefit. 
 
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 
complete upper and lower dentures (D5110, D5120).