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 meets full IRF criteria. The Plan denied 
your request. The Plan says criteria for admission to the IRF 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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 for periodontal maintenance (D4910) provided by a participating 
provider on February 15, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you do not know what is covered and no 
way of knowing which provider is participating. The Plan denied your request. The Plan says the benefit 
frequency limit for D4910 has been met and exhausted. 
 
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 one 
periodontal maintenance per six months.  
 
We looked at the file and Medicare rules. D4910 was previously provided on September 2, 2021. Based on this 
information, we decided that the Plan's rules for coverage of periodontal maintenance have not been met. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a 
participating provider on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the resin-based composite for tooth #14 and 
tooth #18 provided on January 8, 2022, and March 8, 2022. 
 
You asked the Plan to pay the full amount for the resin-based composite for tooth #14 and tooth #18. You say 
that these services should be covered. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. Your contract with the Plan clearly says that you must pay 50% coinsurance for 
Class 2 Basic Services. The Plan contract also says that white fillings on posterior teeth will be processed as a 
silver filling.  
 
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 processes resin-based 
composites as silver fillings.  The record shows the Plan paid their share of your filling under code D2140, 
which is a silver filling. You have been asked to pay $78 for the resin-based composite for tooth #14 and 
tooth #18. 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 pay the full amount for a resin-based composite 
(code D2391) for tooth #14 and tooth #18 provided on January 8, 2022, and March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
February 22, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the services should be covered 
as they were necessary to establish care with your new dentist. The Plan denied your request. The Plan says the 
services denied correctly as you have reached the frequency limit and have had these services performed within 
the last 36 months. 
 
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 pay for a 
comprehensive oral evaluation (D0150) provided on February 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure. 
 
You asked the Plan to pre-approve a Minuteman procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a Minuteman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman procedure is experimental. More research is needed to show safety 
and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on February 8, 2022. 
 
You asked the Plan to waive the coinsurance for an evaluation and prophylaxis. You say that you did not know 
you had a coinsurance for out-of-network providers. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
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 20% 
coinsurance for out-of-network preventive dental services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$10.80, which is 20% coinsurance of the allowed amount for an evaluation ($54 allowed amount x 20% 
coinsurance = $10.80).  You have also been asked to pay $15.60, which is 20% coinsurance of the allowed 
amount for prophylaxis ($78 allowed amount x 20% coinsurance = $15.60). You have been asked to pay a total 
of $26.40 ($10.80 coinsurance + $15.60 coinsurance = $26.40).  An evaluation and prophylaxis fall within the 
Dental Services 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 coinsurance for a periodic oral evaluation 
(D0120) and prophylaxis (D1110) provided on February 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services you are requesting do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for subdural hematoma after a fall. The enrollees medical problems are stable. There are 
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a harness for 
upgrade to expandable controller (E2313) and an expandable controller upgrade (E2377). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the enrollee has Charcot Marie-
Tooth disease with associated severe neuropathy affecting her upper and lower extremities. Her current 
wheelchair is over 9 years old and having increased mechanical problems and in need of replacing. She needs 
tilt and recline function for pressure relief and is at increased risk of ulceration without it. The Plan denied your 
request. The Plan says the requested items do not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a harness for 
upgrade to expandable controller (E2313) and an expandable controller upgrade (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction therapy (97012) provided on July 13 to 
November 29, 2021. 
 
You asked the Plan to pay for mechanical traction therapy. You say that the services at issue were a medical 
necessity for you. The Plan denied your request. The Plan says the services at issue are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for mechanical traction therapy (97012) provided on July 13 to November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (code D5214) provided on 
December 9, 2021. 
 
You asked the Plan to pay for the denture. You say that the cost savings would be better to repair the tooth than 
to remove it. The Plan denied your request. The Plan says only preventive services are covered. Denture 
services are not a covered benefit by the 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 pay for the 
mandibular partial denture (code D5214) provided on December 9, 2021.
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 is waiting for a kidney 
transplant, has complex needs, and needs assistance for pain management. The Plan denied your request. The 
Plan says the enrollee is receiving appropriate inpatient care at the current hospital and is currently unstable for 
transfer. 
 
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 the enrollee does not require services at the LTACH that are not already available at 
the current facility. Transfer to LTACH is not medically necessary as the enrollee is not currently stable for 
transfer and as it would not be clinically advantageous. Completion of treatment at the current facility is 
recommended until stable for transfer. 
 
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 provide additional payment for the crown - porcelain/ceramic 
(D2740) and core buildup, including any pins when required (D2950) provided November 10, 2021. 
 
You asked the Plan to provide additional payment for the crown and core buildup. You say that you do not 
understand how you have hit your maximum already. The Plan denied your request. The Plan says your 
benefits have been paid up to your benefit maximum, and no further payment is due. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown and 
core buildup up to the benefit maximum of $500 per calendar year. 
 
We looked at the file, and Medicare rules. The Plan provided documentation showing that at the time the 
services were rendered you had $195 remaining in your dental benefit maximum. This amount was applied to 
the claim. You have been asked to pay the remaining amount above the $500 benefit. This means you have 
been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan 
does not have to provide additional payment for the crown - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950) provided November 10, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided on October 21, 2021. 
 
You asked the Plan to pay for SNF services. You say that  The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for SNF services provided on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 83540, 83550, 83036, 
84466, 82977, 80050, 84410, 82306 provided December 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says these services are not covered by 
Medicare. These are unbundled services. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, CPTs 83540, 84466, 82977, and 84410 are not a Medicare benefit for the 
diagnoses listed on the claim and are done for screening purposes. Medicare does not cover tests solely for 
screening purposes. Also a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit 
exists between 84466 and 83550. This PTP edit has a modifier indicator of 0, which indicates there are no 
modifiers that are allowed with this PTP code pair. Therefore, we decided that the Plan does not have to pay for 
the laboratory services coded as 83540, 83550, 83036, 84466, 82977, 80050, 84410, 82306 provided December 
16, 2021.
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at 
the current hospital. 
 
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 enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary as the enrollee is 
unstable at the time. Completion of treatment at the current facility is recommended until more stable for 
transfer. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from January 26, 2022, 
through February 9, 2022. 
 
You asked the Plan to pay for chiropractic services. The Plan denied your request. The Plan says the member's 
plan excludes coverage for this out-of-network service. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for chiropractic services provided from January 26, 2022, through 
February 9, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for osteomyelitis. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee 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.