Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
lumbar laminectomy and will need inpatient admission after surgery. The Plan denied your request. The Plan 
says there is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a lumbar laminectomy. The record does not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup (D2950) and crown (D2751) for tooth 
#20. 
 
You asked the Plan to pre-approve the core buildup and crown. You say that these services are necessary. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 the core 
buildup and crown 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 the core buildup and crown. Our 
reviewer says that the criteria for coverage of these services have not been met in this case. Our physician 
reviewer found that the provided radiograph shows a heavily worn tooth, with similar wear seen on the other 
teeth in the lower arch. There appears to be a notch on #20, possibly a fracture, that could be restored with a 
conventional material. The Plan requires that permanent molar teeth must have pathologic destruction to the 
tooth by caries or trauma, and that destruction should involve four or more surfaces and two or more cusps, and 
that permanent bicuspid (premolar) teeth must have pathologic destruction to the tooth by caries or trauma, and that destruction should involve three or more surfaces and at least one cusp. In this instance, there is noted wear 
on the occlusal aspect, but no clear caries and only a small existing occlusal restoration along with what 
appears to be a small fracture. There are insufficient surfaces involved to require a crown restoration under the 
Plan criteria, particularly as the majority of the tooth damage is from wear and not from caries or trauma. In 
this instance there is no necessity for a crown, and therefore neither a core buildup for a crown. 
 
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 the core buildup and crown have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a core buildup (D2950) and crown (D2751) for tooth #20.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric care from May 30, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services from May 30, 2022, forward. You say 
that the services at issue are medically necessary. The Plan denied your request. The Plan says that the services 
at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services 
from May 30, 2022, forward. Our reviewer says that the enrollee meets the criteria for acute inpatient mental 
health treatment beyond the date in question of May 30, 2022, forward. Our physician reviewer found the 
enrollee was a danger to herself but not others. It did appear that active treatment was taking place beyond the 
date in question. It did appear that the services were reasonably expected to improve the enrollees condition or 
for the purpose of diagnosis beyond the date in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services from May 30, 2022, forward have been 
met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric care from May 30, 2022, 
forward.  
   
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311). 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for you. The Plan denied your request. The Plan says medical 
necessity rules for coverage of the requested items 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 an expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that you do not require non-proportional input devices 
(e.g., sip and puff, head array, etc.). You do not require a separate display (i.e., for alternate control devices), 
other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. You have 3 power options of tilt, recline, and power elevating leg rests but 
you do not need to control the power options through a joystick. Your upper extremity strength and function 
support that you can control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft - retained natural tooth - first site 
in quadrant (D4263) and guided tissue regeneration - resorbable barrier, per site (D4266) provided February 10, 2022. 
 
You asked the Plan to pay for the bone replacement graft and guided tissue regeneration. You say that you 
would like the services covered. The Plan denied your request. The Plan says these services are not covered 
under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft - retained natural tooth - first site in quadrant (D4263) and guided tissue regeneration - resorbable barrier, per site (D4266) provided February 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled 
medications. The enrollee had stable vital signs, her lungs were clear and she had a dressing to her left knee 
wound. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7311 
x2), removal of torus mandibularis (D7473 x2), and removal of torus palatinus (D7472 x2). 
 
You asked the Plan to pre-approve alveoloplasty in conjunction with extractions, removal of torus 
mandibularis, and removal of torus palatinus. You say that the requested services are medically necessary. The 
Plan denied your request. The Plan says the services at issue are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
alveoloplasty in conjunction with extractions (D7311 x2), removal of torus mandibularis (D7473 x2), and 
removal of torus palatinus (D7472 x2).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after May 4, 2022. 
 
You asked the Plan to pre-approve SNF care after May 4, 2022. You say that the continued admission to a SNF 
is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is not 
medically necessary. 
 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 after May 4, 2022. Our 
reviewer says that continued daily skilled services are not necessary. Our physician reviewer found based on 
the medical records provided there is no documentation that the enrollee requires the services on an inpatient 
basis, only in a skilled nursing facility 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 after May 4, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on August 26, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you would like these 
services to be paid. The Plan denied your request. The Plan says these services were rendered by an OON 
provider. The Plan also says that there was no prior authorization on file for these dental services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120) and prophylaxis (D1110) provided on August 26, 2020 by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on November 23, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you feel like the Plan should pay 
for this. The Plan denied your request. The Plan says D0150 had been correctly denied. 
 
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 
comprehensive oral evaluation every 36 months. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on October 7, 2021. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for 
a comprehensive oral evaluation (D0150) provided by a participating provider on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis 
(D1110) provided on November 23, 2021, by the out of network dentist. 
 
You asked the Plan to pay for the oral evaluation and prophylaxis. You say that you were unaware of the 
provider's contract. You say that you did your due diligence to ensure you did not have unexpected charges. 
You also say that this should be covered. The Plan denied your request. The Plan says dental services received 
out of network 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on November 23, 2021, by the out 
of network dentist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder arthroscopy services coded 29805 provided on 
December 10, 2021. 
 
You asked the Plan to pay for the shoulder arthroscopy. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has denied correctly based on 
the assistant surgery indicators for payment.  
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the shoulder arthroscopy services 
coded 29805 provided on December 10, 2021, have been met. Specifically, no medical records were provided 
to corroborate the services as they were billed. Therefore, we decided that the Plan does not have to pay for the 
shoulder arthroscopy services coded 29805 provided on December 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you received oral medications and had stable 
vital signs. Your lungs were clear, you had routine foley catheter care and you were treated for pain. You do 
not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity 
of service criteria for an inpatient basis in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies (A4556, A4630) provided from April 
11, 2021, through July 10, 2021. 
 
You asked the Plan to pay for the medical supplies. You say that you would like these claims reprocessed and 
approved for payment. The Plan denied your request. The Plan says these claims have not been billed as 
required by Medicare coding regulations. 
 
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 looked at the file and Medicare rules. In this case, code A4556 has a Status Code of "P" under the 
Physician Fee Schedule indicating that this is a bundled/excluded code that is not eligible for separate payment. 
In addition, code A4630 has a Status Code of "X" under the Physician Fee Schedule indicating that it is 
classified as a statutory exclusion and not eligible for payment. Based on this information, we decided that 
Medicare rules for coverage of the medical supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical supplies (A4556, A4630) provided from April 11, 2021, through July 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 8, 9, and 10. 
 
You asked the Plan to pre-approve the crowns. You say that while the fillings on these teeth appear solid in the 
x-ray, the amount of enamel wear is not so obvious. The Plan denied your request. The Plan says the x-rays 
show crowns are not needed to fix your teeth. 
 
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 crowns 
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 the crowns. Our reviewer says that the 
crowns are not medically necessary. Our physician reviewer found the provided x-rays reveal heavily worn 
upper anterior teeth, with the majority of the structure clearly missing from wear and attrition. The restorations 
on tooth #'s 8 and 9 each appear to be two surfaces, with the majority of missing structure from wear. The Plan 
provides for crown restorations where there are multiple involved surfaces including the incisal, but not where 
there is loss due to attrition, abrasion, or erosion. Our reviewer found that in this case the majority of the 
structural loss is clearly due to abrasion or attrition. Our physician reviewer also found that as the Plan does not 
provide for crowns where the loss of structure is due to attrition, abrasions or erosion, there would be no 
necessity for crowns on the requested teeth. 
 
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 the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2740) for tooth #'s 8, 9, and 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2740) and core buildups, including any pins 
when required (D2950) provided on September 21, 2021. 
 
You asked the Plan to pay for the crowns and core buildups. You say that the provider received confirmation 
that you had coverage for these services. The Plan denied your request. The Plan says these services are not 
covered expenses under your dental plan. When you contacted the Plan prior to this date of service, you asked 
about participating providers, but no benefits of the Plan were discussed. The Plan also says that there is no 
record of the provider contacting the Plan prior to this date of service, and the estimate of coverage came from 
what the provider had notated within their own system. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
crowns (D2740) and core buildups, including any pins when required (D2950) provided on September 21, 2021.