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

 
We decided that the Plan does not have to pre-approve bone graft at time of implant placement tooth #30 
(D6104), guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery tooth 
#30 (D3432), gingival irrigation  per quadrant (D4921 x4), and surgical access to an implant body tooth #30  
(second stage implant surgery) (D6011). 
 
You asked the Plan to pre-approve dental codes D6104, D4342, D6011 all for tooth #30, and D4921. You say 
that these services are medically necessary. The Plan denied your request. The Plan says these services are not 
covered under the benefit package. 
 
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 bone 
graft at time of implant placement tooth #30 (D6104), guided tissue regeneration, resorbable barrier, per site, in 
conjunction with periradicular surgery tooth #30 (D3432), gingival irrigation  per quadrant (D4921 x4), and 
surgical access to an implant body tooth #30  (second stage implant surgery) (D6011).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services (procedure codes 99233 and 99291) 
provided to the enrollee from March 2, 2022, to March 4, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 99233: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
 CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records show the patient being 
part of a critical care visit, however, the provided documentation did not confirm the length of this visit was 30-
74 minutes long or at least 50 minutes long on the billed date of service to support the CPT codes 99291 or 
99233 as submitted. Therefore, the records do not support these codes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital services (procedure codes 99233 and 99291) provided to the enrollee from March 2, 
2022, to March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of two dental implants and a 
dental night guard. 
 
You asked the Plan to pre-approve the dental services. You say that you need the additional implants and that 
without a dental night guard you will continue to bite your tongue in your sleep. The Plan denied your request. 
The Plan says these services are either not covered under your dental plan or your benefit for the requested item 
or service has been 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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted authorization request 7731483 when the 
Plan approved two of the four requested dental implants. Therefore, we decided that the Plan does not have to 
pre-approve the surgical placement of two additional dental implants and a dental night guard.
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 were independent and active before being in the 
hospital, and you want to return to being independent. You say you are eager to participate and complete the 
required three hours of therapy, and you will not get that in a nursing home. 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is necessary because at 
this time, the services required for the enrollee cannot be safely met with home health services or a skilled 
nursing facility. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
for admission IRF. 
 
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 enrollee's nursing, medical, and rehabilitation needs does not require an IRF stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted on 
February 6, 2023, for weakness after missing hemodialysis. He was discharged home after hemodialysis and 
has ongoing weakness. The enrollees medical problems are stable, and 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 medical record 
supports a need for physical therapy and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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 an IRF admission and services.
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 services are medically necessary. The 
Plan denied your request. The Plan says the LTACH services requested do not meet the requirements for 
approval. 
 
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 available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on June 9, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 
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 the urinary tract infection panel was not billed with a single code as required. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the panel testing provided on June 9, 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 the enrollee needs close monitoring of 
labs and vital signs. The Plan denied your request. The Plan says the enrollee records do not show you need 
continued treatments and care that can only be given in a hospital setting. When ready to leave the hospital, 
services may be received from a lower level of care. 
 
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 available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you fell on New Year's Eve and bruised your back, 
currently can barely get around, and now need rehabilitation to regain strength and mobility. The Plan denied 
your request. The Plan says you are medically stable at home with a decline in function, do not have acutely 
complex medical diagnosis and do not require supervision by a rehabilitation physician. 
 
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 treatment by multiple therapies, including either 
physical or occupational therapy, and an intensive rehabilitation therapy 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that specimens are received from providers. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and abutment 
supported crown (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary due 
to major infection in your gums and jawbone and should be covered. The Plan denied your request. The Plan 
says these services are not covered by the Plan's dental benefits. 
 
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 
prefabricated abutment (D6056) and abutment supported crown (D6058).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the requested SNF services requested do not 
meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 the enrollee will clearly benefit from acute rehab to 
optimize their level of functioning prior to returning home. The Plan denied your request. The Plan says the 
request for an IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has had a decline from their baseline level of function and may benefit from therapy, but they do not require the 
intensity of therapies provided on acute inpatient rehabilitation. 
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services will give the enrollee the best outcome 
possible to safely return home and to the community. The Plan denied your request. The Plan says the request 
IRF services are not medically necessary. 
 
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 upon review of the available records, the enrollee does not meet coverage criteria 
for an IRF admission. The enrollee is medically stable with no acute medical problems and does not need a rehabilitation physician's 
supervision 3 times a week in an IRF. No acute rehabilitation nursing needs were identified or documented. 
At the current functional level, the enrollee is not expected to make significant functional recovery in a 
reasonable period in an IRF. The enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. The documentation does 
not support the necessity for admission to an IRF and the complexity of the enrollee's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitative care. While the enrollee may have a need for physical therapy and/or occupational therapy, the 
enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in a skilled 
nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sclerotherapy of single vein, bilateral legs (36470).  
You asked the Plan to pre-approve sclerotherapy. You say that please consider this pertinent medical history to 
consider coverage for the ultrasound guided sclerotherapy. The Plan denied your request. The Plan says the 
medical records received do not support that the referenced medical criteria in the LCD have 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 sclerotherapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it is not clear that the patient is having lifestyle limiting symptoms in the left leg.  The patient 
presented when she developed thrombophlebitis in the right great saphenous vein, and it is noted the right is 
more bothersome than the left.   However, criteria also require that the patients symptoms be due to the veins 
in question.  It is not possible to attribute the patients leg discomfort to residual varicose veins without an 
assessment of lower extremity arterial perfusion.  In this case, there is no documentation that demonstrates 
satisfactory perfusion to lower extremities bilaterally.  Lastly, there remains significant truncal reflux on the 
right therefore the criteria on requiring that truncal reflux be previously eliminated prior to consideration of 
coverage of sclerotherapy has also not been met. The documentation does not support medical necessity of the 
treatments in question and does not meet coverage criteria.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the sclerotherapy of single vein, bilateral legs (36470).