Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 test kit. 
 
You asked the Plan to pay for a COVID-19 test kit. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this is not a covered item. 
 
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.  
 
 In this case, although Medicare has approved coverage of COVID-19 test kits, this only started in April 2022. 
This kit was purchased before this date. Therefore, we decided that the Plan does not have to pay for a COVID-
19 test kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 5 and 7 and retainer 
crowns (D6750) for tooth #'s 4, 6, and 8. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. The Plan denied your request. The Plan 
says to approve a bridge, you must be missing only one upper front tooth or only two lower front teeth. The 
two lower front teeth must be next to each other. You also cannot be missing any of your back teeth. The Plan 
also says that the x-rays show you are missing other 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 pontics 
and retainer 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 pontics and retainer crowns. Our 
reviewer says that the pontics and retainer crowns are not medically reasonable and necessary. Our physician 
reviewer found there will be two teeth being replaced, one in the posterior region (tooth #5), and a a failing 
tooth #15 that will require removal in the upper left posterior segment. Our reviewer also found that as there 
are missing posterior teeth, and the less costly option would be to use a removable appliance, there would be no 
necessity for the requested bridge under the Plan provisions. 
 
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 pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6240) for tooth #'s 5 and 7 and retainer crowns (D6750) for 
tooth #'s 4, 6, and 8.
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 need to go to the rehabilitation facility to help 
you gain strength and learn to walk safely. You also say that you need assistance with daily tasks like bathing. 
The Plan denied your request. The Plan says the Inpatient Rehabilitation Facility (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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer 
also found that there is not a reasonable expectation that you 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings. 
 
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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Saxenda Solution Pen. 
 
You asked the Plan to pre-approve Saxenda. You say that the enrollee has an increased body mass index 
(BMI). You also say that the enrollee is not able to decrease it with diet, or physical activity by itself. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare 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 Saxenda Solution Pen.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services coded 86850, 86880, 86900, 
86901 and 86922 provided on November 30, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like this claim 
reprocessed and approved as you believe they were underpaid. The Plan denied your request. The Plan says 
these codes are not separately payable per the Outpatient Prospective Payment System. 
 
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, the cited codes have a Payment Status Indicator of Q1 
indicating that these codes will be considered packaged and not separately payable under certain circumstances. 
The circumstance that applies in this case is that these codes have been billed on the same claim as code 96413 
which has a Status Indicator of S. This means that no separate payment will be made according to Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital 
services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital 
services coded 86850, 86880, 86900, 86901 and 86922 provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on 
January 25, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that 
the services would not be covered. You also say that your counselor told you otherwise. 
The Plan denied your request. The Plan says crown and core build up are not listed as covered 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 crown and core build up are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) and core build up (D2950) provided on January 25, 2021.
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 would like to appeal the Plan's denial for IRF 
services for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
an admission to 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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our 
physician reviewer also found that there is not a reasonable expectation that this patient 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the critical care, evaluation and management of the critically ill or 
critically injured patient; first 30-74 minutes (99291) provided on November 12, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services should be 
covered. The Plan denied your request. The Plan says that the claim was processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not include evidence as to why procedure code 99291 
is not payable. Therefore, we decided that the Plan has to pay for the critical care, evaluation and management 
of the critically ill or critically injured patient; first 30-74 minutes (99291) provided on November 12, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services (88305, 88312) provided on 
November 10, 2021. 
 
You asked the Plan to pay for the pathology services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim is included in payment to the 
facility. 
 
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, the records indicate that the member was an outpatient 
on the billed date of service. Payment for CPT code 88305 is included in the payment to the facility and is the 
responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for 
coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay 
for the pathology services (88305, 88312) provided on November 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a SNF admission. You say that you are at a higher risk remaining in the 
hospital, and need the next level of care with rehabilitation. The Plan denied your request. The Plan says your 
request for an admission to skilled nursing facility does 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 a SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do 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 a SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services have not been billed as 
required by Medicare coding regulations. 
 The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results. 
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate remains experimental. More research is needed. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on December 16, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you were unable to obtain pre-authorization. The 
Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance. 
 
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 file shows that the enrollee received a wheeled walker. The provider in this case is not a network provider 
with the Plan. The Plan had network providers available who could have provided the item at issue in this 
appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to 
pay for the item at issue. Therefore, we decided that the Plan does not have to pay for the durable medical 
equipment provided on December 16, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 29, 
2021, to May 30, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the inpatient level of care was not medically necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two 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 pay for the acute inpatient hospital care provided from May 29, 2021, to May 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 6, 7, 8, 9, 10, and 12 and 
retainer crowns (D6750) for tooth #'s 4, 5, 11, and 13. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you would like these services 
to be reconsidered for coverage. The Plan denied your request. The Plan says to approve a bridge, you must be 
missing only one upper front tooth or only two lower front teeth. The two lower front teeth must be next to 
each other. You also cannot be missing any of your back teeth. The Plan also says that the x-rays show you are 
missing other 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 pontics 
and retainer 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 pontics and retainer crowns. Our 
reviewer says that the criteria under the Plan has not been met. Our physician reviewer found the request was 
made for a multi-unit bridge spanning tooth #'s 4 to 13, replacing tooth #'s 6, 7, 8, 9, 10, and 12. The upper arch 
is also missing tooth #'s 2, 14, and 15 in the posterior region. Our reviewer found that in this case there are 
multiple missing teeth in the upper arch (10).  Our physician reviewer also found that as there is no coverage 
provided for fixed bridges in cases where there is more than one missing tooth in the upper anterior arch, there 
would be no necessity in this case due to the numerous missing teeth noted above. 
 
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 pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6240) for tooth #'s 6, 7, 8, 9, 10, and 12 and retainer crowns 
(D6750) for tooth #'s 4, 5, 11, and 13.