Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the enrollee does not 
require an intensive level of therapy requiring physician oversight and 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 was admitted to the hospital on January 19, 2023 for pneumonia and an exacerbation of his 
chronic obstructive pulmonary disease. The enrollee does not require rehabilitation for complex nursing care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 
hours over seven consecutive days. The enrollee has had a decline from his baseline level of function and may 
benefit from therapy but does not require the intensity of therapies 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone tablets. 
 
You asked the Plan to pre-approve Dexamethasone tablets. You say that this drug is for the prevention of 
nausea and vomiting associated with cancer chemotherapy. You also say that the drug is being administered 
within two hours of cancer chemotherapy, and is not being used as a full therapeutic replacement for 
intravenous anti-emetic therapy. The Plan denied your request. The Plan says this medication is not used as a 
full therapeutic replacement for intravenous anti-emetic drugs that would have been administered at the time of 
the cancer chemotherapy treatment. The appeal for Dexamethasone does not meet Medicare criteria for 
coverage under Part B. 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone tablets.  
 
Benefits for Dexamethasone tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray exam of the spine (72100), chiropractic manipulative 
treatment spinal 1-2 regions (98940), evaluation and management office visit (99212) and ultrasound therapy 
(97035) provided on June 9, 2022. 
 
You asked the Plan to pay for chiropractic services. You say that you received these services in an emergency 
situation. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 
item/service at issue. Therefore, we decided that the Plan does not have to pay for x-ray exam of the spine 
(72100), chiropractic manipulative treatment spinal 1-2 regions (98940), evaluation and management office 
visit (99212) and ultrasound therapy (97035) provided on June 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH as they cannot be adequately cared for in their current condition at a lower level of care. 
You say that the enrollee is at high risk for a respiratory decompensation. The Plan denied your request. The 
Plan says an LTACH admission is not medically necessary, and the enrollee can get the care they need in the 
current hospital setting. 
 
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 that the enrollee is still unstable and requires short-term additional acute care hospital 
services that can be safely provided at the current facility until they are more stable and ready for 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
intraoral periapical x-ray (D0220) and palliative treatment of dental pain (D9110) provided on August 31, 
2022. 
 
You asked the Plan to pay for the dental services. You say that this was a medical injury and may need future 
treatment. 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 pay for the 
problem focused limited oral evaluation (D0140), intraoral periapical x-ray (D0220) and palliative treatment of 
dental pain (D9110) provided on August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 provided on August 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that a more complex drug screening was provided. The 
Plan denied your request. The Plan says the testing is not separately billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. 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 procedure code 83789 provided on August 16, 2022.
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 you are appealing this denial. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare guidelines for services in an 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 the complexity of the enrollee's documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on September 16, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
September 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays on July 05, 2022. 
 
You asked the Plan to waive the copayment for x-rays. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 a $85 
copayment per visit for the listed Medicare-covered services performed in outpatient hospital facility. Covered 
services include but are not limited to X-rays and other radiology services billed by the hospital. The provider 
billed in the amount of $1,168 and the allowed amount is $35.82. This is less than the copayment amount. 
Therefore, results in the total cost sharing amount of $35.82. 
 
 
 
 
 You have been asked to pay a $35.82 copayment, which is less than copayment for x-rays. This item/service 
falls within the Outpatient hospital 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 copayment 
for x-rays on July 05, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional 
services. 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended.  
 
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental re-evaluation (D0171) and periapical x-rays (D0220, 
D0230) provided on September 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the x-rays (D0220, D0230) has 
already been exhausted and coverage for the dental re-evaluation (D0171) denied correctly as they do not fall 
within your 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service 08/15/2022. Therefore, 
we decided that the Plan does not have to pay for a dental re-evaluation (D0171) and periapical x-rays (D0220, 
D0230) provided on September 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's current condition and 
needs are a priority, and their potential recovery can be met faster in an LTACH setting. The Plan denied your 
request. The Plan says admission to an LTACH is not medically necessary. 
 
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. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) provided on September 9, 2022. 
 
You asked the Plan to pay for the immunization. You say that this should be covered. You say that it is an 
ordinary wellness item. The Plan denied your request. The Plan says the immunization you received is not 
covered under your medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715) provided on September 9, 2022.  
 
Benefits for the immunization may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an ILR. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
memory loop recorder.  
 
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 ILR. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no report of the patient having 
recurrent syncope or a cryptogenic stroke to support this type of event monitoring. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) (33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supplies billed for date of 
service September 15, 2022. 
 
You asked the Plan to pay for the billed services. You say that the provider is aware the enrollee is using the 
device. The Plan denied your request. The Plan says the date of service does not match the records. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain valid proof of delivery for the billed date of service. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the continuous glucose monitor supplies billed for date of service September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urology visit and labs provided on March 08, 2022. 
 
You asked the Plan to pay for a urology visit and labs. You say that you had two appointments here before and 
they were covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a urology visit and labs 
provided on March 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for procedure code 71250. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 71250 is bundled into 
payment for code 71275. 
 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 71250 
is a column II code to column I code 71275. 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 71250 billed for date of service August 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says your 
plan only covers 60 one-way trips, and you have used up all of these trips. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation  problem focused (D0140) and 
intraoral  periapical first radiographic image (D0220) provided on August 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your 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 pay for a limited 
oral evaluation  problem focused (D0140) and intraoral  periapical first radiographic image (D0220) 
provided on August 17, 2022.