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

 
We decided that the Plan does not have to pre-approve a partial hospital program. 
 
You asked the Plan to pre-approve a partial hospital program. You say that you have a lot of anxiety, 
nervousness, you cannot concentrate, you have a lot of stress and a desire to cry for no reason. The Plan denied 
your request. The Plan says the requested partial hospital program is not medically necessary. 
 
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 a partial hospital program. Our 
reviewer says that the requested partial hospital program is not considered medically reasonable and necessary 
in this case. Our physician reviewer found that there is no indication in the available medical records that your 
psychiatric symptoms could not be managed on a less restrictive basis. You have not expressed any active 
suicidal ideation or intent, or any intent to harm yourself or anyone else. You have not exhibited any other significant symptoms such as psychosis or mania. There is no indication of moderate social dysfunction or 
worsening of any medical comorbidities. You had no acute psychiatric issues that would require partial 
psychiatric hospitalization. You have been treated with medications in an outpatient setting without any 
adverse effects. The available medical records do not support that the requested psychiatric care is medically 
necessary to optimize pharmacotherapy for your symptoms. 
 
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 partial hospital program have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a partial hospital program.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for coagulability (F2 and F5 gene 
analysis) (81240,81241). 
 
You asked the Plan to pre-approve the genetic testing. You say that the records provided support the necessity 
of the requested service. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. Genetic testing for these variants in genes is non-covered except for 
when pregnant. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing for 
coagulability (F2 and F5 gene analysis) (81240,81241).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, 
kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar 
(22514). 
 
You asked the Plan to pre-approve the surgery. You say that this si medically necessary. The Plan denied your 
request. The Plan says the fracture is more 12 weeks old. 
 
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 the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the guidelines do not support kyphoplasty for compression fractures that are not acute (less than six 
weeks) or subacute (6-12 weeks). This is not evident in this case. Moreover, there is notation of fracture 
retropulsion along with neural impingement, which are relative contraindications. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; lumbar (22514).
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 meets LTACH admission 
criteria. The Plan denied your request. The Plan says the request 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says based on the 
information submitted there is no documentation that you meet the criteria. 
 
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 SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan attempted to obtain this 
information, but it was not received. Without medical records we are unable to determine if you meet the 
criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental 
benefits for the chronically ill (SSBCI).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services billed with codes 99204 
and 96132 for August 8, 2022, 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 outpatient mental health services billed with 
codes 99204 and 96132 for August 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99213 billed for date of service September 29, 2022. 
 
You asked the Plan to pay for code 99213. You say that you have seen this patient multiple times and all 
previous claims were paid. The Plan denied your request. The Plan says that you billed with an incorrect place 
of service. 
 
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 Plan's sole rationale for denial in its case file submission to us is 
that this claim was billed with an inappropriate place of service.  This is not true.  The code billed (99213) is an 
office visit code.  You billed with Place of Service 11, which is an office setting, so this is correct.  The Plan 
has set forth no other reason for denying this claim.  The burden is on the Plan to show why its denial was 
appropriate, and the Plan has failed to do so in this case. Therefore, we decided that the Plan has to pay for 
code 99213 billed for date of service September 29, 2022.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 
23, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 97010 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, heavy duty, extra wide, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds with any type side rails, with mattress 
(code E0303). 
 
You asked the Plan to pre-approve a hospital bed, heavy duty, extra wide, with weight capacity greater than 
350 pounds, but less than or equal to 600 pounds with any type side rails, with mattress. You say that the 
patient has a diagnosis of congestive heart failure , chronic obstructive pulmonary disease (COPD), asthma and 
needs an adjustable bed to facilitate more effective breathing at nighttime. You say that the patient also reports 
it will help alleviate pain from a worn-out bed. The Plan denied your request. The Plan says under the Medicare 
rules a heavy-duty hospital bed is not medically necessary because the enrollees weight is not more than 350 
pounds. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed 
(E0301, E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the 
beneficiary's weight is more than 350 pounds but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. The file shows that the enrollees weight is not more than 350 
pounds. Based on this information, we decided that Medicare rules for coverage of a hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds with any type 
side rails, with mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 
600 pounds with any type side rails, with mattress (code E0303).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 4, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 97010 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you would like to appeal because you 
received a letter saying you were denied the card utilities. The Plan denied your request. The Plan says based 
on the information submitted, there is no documentation that you meet the criteria. 
 
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 SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan attempted to obtain this 
information, but it was not received. Without medical records we are unable to determine if you meet the 
criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental 
benefits for the chronically ill (SSBCI).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot be safely discharged at this time, you 
need SNF services in order to get strength and return home independent. The Plan denied your request. The 
Plan says the request 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. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim partial denture (including retentive/clasping 
materials, rests, and teeth), maxillary (D5820), retainer crown - porcelain fused to predominantly base metal 
tooth #'s 6 and 11 (D6751), retainer - porcelain/ceramic for resin bonded fixed prosthesis tooth #'s 7 and 8 
(D6548), and pontic - porcelain fused to predominantly base metal tooth #'s 9 and 10 (D6241). 
 
You asked the Plan to pre-approve the dental services represented by codes D5820, D6751, D6548 and D6241. 
The Plan denied your request. The Plan says these 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 dental 
services represented by codes D6751, D6548 and D6241 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 dental services represented by codes 
D6751, D6548 and D6241. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the proposed bridge is not medically necessary. Teeth #7 and 8 have been extensively restored 
following endodontic treatment and are treatment planned for lingual bonded wings to allow for a connection 
of the bridge between #6 and 11 The rebuilt condition of #7 and 8 would lead to more likely structural 
breakdown due to the more that 50% damage to each of these teeth, and it would potentially compromise a 
long span bridge if they failed. The treatment plan should be reconsidered. In this case there are multiple 
missing posterior teeth including #'s 1, 2, 4, 13, 14 and 16 as well as two missing upper missing anterior teeth 
namely #9 and 10. As there is no coverage allowed in the situation as presented, there is not necessity for the 
requested bridge procedure. 
 
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 dental services represented by codes D5820, D6751, D6548 and D6241 
have not been met. Therefore, we decided that the Plan does not have to pre-approve interim partial denture 
(including retentive/clasping materials, rests, and teeth), maxillary (D5820), retainer crown - porcelain fused to 
predominantly base metal tooth #'s 6 and 11 (D6751), retainer - porcelain/ceramic for resin bonded fixed 
prosthesis tooth #'s 7 and 8 (D6548), and pontic - porcelain fused to predominantly base metal tooth #'s 9 and 
10 (D6241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you want to appeal the Plan denial. The Plan 
denied your request. The Plan says based on the information submitted, there is no documentation that you 
meet all three criteria. 
 
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 SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan attempted to obtain this 
information, but it was not received. Without medical records we are unable to determine if you meet the 
criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental 
benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on September 7, 2022. 
 
You asked the Plan to pay for the medical services. You say that the physician provided medically necessary 
services and the claim should be paid. The Plan denied your request. The Plan says this claim needs to first be 
processed by the patient's primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted 
you multiple times to instruct you to bill the primary insurer.  They called and left you a voice mail with this 
information on February 10, 2023, and they faxed this information to you on the same date as well. To date, 
there is no evidence that you have submitted this claim to the patient's primary insurer. As the secondary 
insurer, the Plan cannot be held responsible for the medical services until the primary insurer has denied the 
claim for these services. Therefore, we decided that the Plan does not have to pay for medical services provided 
on September 7, 2022.