Persius/hicric huggingface dataset:
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 is receiving appropriate care at the present acute care hospital. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 2, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the necessary
documentation was not submitted.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. The records provided do not contain
documentation of the ordering physician's intent that the tests be performed. 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 February 2, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting such as 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 acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740), core buildup (D2950), guided tissue
regeneration (D4266), gingival irrigation (D4921) and bone replacement graft (D7953).
You asked the Plan to pre-approve the crown (D2740), core buildup (D2950), guided tissue regeneration
(D4266), gingival irrigation (D4921) and bone replacement graft (D7953). The Plan denied your request. The
Plan says the services 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 the
crown (D2740), core buildup (D2950), guided tissue regeneration (D4266), gingival irrigation (D4921) and
bone replacement graft (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an excision of a lesion on the tongue (41112) to be provided by an out of network oral surgeon.
You asked the Plan to pre-approve the surgical service. You say that your primary care physician (PCP) has referred you for this service. The Plan denied your request. The Plan says the requested service is not urgent or emergent. The Plan also says that there are in network oral surgeons that can provide the service you requested.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the surgical service at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an excision of a lesion on the tongue (41112) to be provided by an out of network oral surgeon
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion services provided on March 30, 2021 to April
19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the infusion services provided on March 30, 2021 to April 19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth visit with a specialist provided
on August 3, 2021.
You asked the Plan to waive the copayment for a telehealth visit with a specialist. You say that you disagree
with the charges because your condition has not improved. The Plan denied your request. The Plan says the
claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for specialist visits, including telehealth services.
You have been asked to pay a $40 copayment for a telehealth visit with a specialist. A telehealth visit with a
specialist falls within the physician/practitioner services, including doctor's office visits 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 a telehealth visit with a specialist provided on August 3,
2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions.
You asked the Plan to pre-approve the dental services. You say that you need your teeth out because you are in
pain. The Plan denied your request. The Plan says routine dental services are not covered by Medicare or the
Plan.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve extractions.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided from May 12, 2021, to June 11, 2021.
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that you were under the impression that your stay would be completely covered because each stay was less than twenty days. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 per day for days 1-20 and $100 per day for days 21-100 for each skilled nursing facility admission.
The record shows you were in the skilled nursing facility from May 12, 2021, to May 19, 2021 (7 days) and again from May 26, 2021, to June 11, 2021 (16 days). The record also shows that between your SNF stays you were at the hospital. This means that all your SNF days are within the same benefit period. The total SNF days for this benefit period is 23 days. There is a $0 copayment for the first 20 days of a benefit period. You have been asked to pay a $100 copayment per day for three days of skilled nursing facility services. Please note that you are not charged for the discharge day. Skilled nursing facility services falls within the Skilled Nursing Facility (SNF) Care 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 skilled nursing facility services provided from May 12, 2021, to June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve collection and application of autologous blood concentrate product (D7921) and core build up (D2950) for tooth # 4.
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says collection and application of autologous blood concentrate product is not listed as a covered service. The Plan says that core build up is not listed as a covered service either.
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 collection and application of autologous blood concentrate product, and core build up are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve collection and application of autologous blood concentrate product (D7921) and core build up (D2950) for tooth # 4.
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 admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the 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 based on the documentation provided the enrollee only requires short-term additional
acute care services that can safely be administered at the current facility. The enrollee does not require services
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the
enrollee requires that are not already available and covered 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 long term acute care hospital (LTACH)
services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
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. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation (D9222 and D9223).
You asked the Plan to pre-approve deep sedation (D9222 and D9223). You say that you were informed by the
facility that the sedation would not be covered so you have to pay $190 out-of-pocket. You say that the
sedation fee should be covered at least partially if not in full. The Plan denied your request. The Plan says the
service is not a covered benefit.
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 deep
sedation (D9222 and D9223).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for the lower partial denture (D5212).
You asked the Plan to pre-approve for the lower partial denture (D5212). You say that your denture broke. The
Plan denied your request. The Plan says this procedure is only covered once every five plan years.
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, you also have a maximum benefit of
one lower partial denture (D5212) every five plan years. The Plan paid for the lower partial denture (D5212)
provided on April 30, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to
pre-approve for the lower partial denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 12, 13, 20, and 21.
You asked the Plan to pre-approve the crowns. You say that you would like the crowns to be reconsidered for
coverage. The Plan denied your request. The Plan says the x-ray shows no decay and over half of the bone is
gone on these teeth. The Plan also says that crowns are not needed to fix these 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
criteria for coverage has not been met. Our physician reviewer found the crowns being requested for tooth #'s
12, 13, 20, and 21 have been noted as specifically for the purpose of stabilizing the teeth due to increased
mobility. Our reviewer found that the teeth do not have any notable breakdown of structure from fracture or
decay. In general, crowns may be considered where there is extensive breakdown of the coronal tooth structure
and strength is required when restoring it. The Plan provides that crowns will not be a covered service if
"Splinted Crowns are being requested". Our physician reviewer also found that in this instance the sole reason
for the crowns would be for splinting the teeth to add stability, which is specifically excluded from coverage
under the Plan.
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 12, 13, 20, and 21.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, 83789, G0480) provided on July 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that You say that routine urine drug testing is necessary to monitor the use of these prescriptions as a part of the Prescription Drug Monitoring Program. The Plan denied your request. The Plan says you are not a network provider with the Plan. The Plan also says that the services were not referred by a network provider or rendered in an in-network facility, the services were not urgent or emergent, and the services 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 Plan contract also says that you must obtain authorization
from the plan prior to seeking care from an out-of-network provider. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing (80307, 83789, G0480) provided on July 13, 2021 by an out-of-network (OON) provider
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 admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the 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 based on the documentation provided the enrollee only requires short-term additional
acute care services that can safely be administered at the current facility. The enrollee does not require services
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the
enrollee requires that are not already available and covered 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 long term acute care hospital (LTACH) services.