Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 7, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. In this case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on January 7, 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 the SNF admission. You say that this enrollee is not safe to discharge home 
without first going to rehabilitation. You also say that the enrollee will likely have a massive decline in 
functioning if not fall and cause irreversible damage or death. The Plan denied your request. The Plan says this 
request for an admission to a SNF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90834) provided on September 16, 2021. 
 
  You asked the Plan to pay for the psychotherapy (90834). You say that the physician provided medically 
necessary services that are consistent with generally accepted principles of professional medical practice. You 
say that the claim should be timely processed for payment. The Plan denied your request. The Plan says the 
provider must attempt to consult the attending or primary care physician about the services furnished. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy (90834) have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for psychotherapy (90834) 
provided on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) provided by a contracted provider 
on September 22, 2021. 
 
You asked the Plan to pay for intraoral imaging. You say that you were given the wrong information. You say 
that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for 
D0210 has already been met. 
 
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 intraoral 
imaging once every two years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D021 was provided on 
September 15, 2020. Based on this information, we decided that the Plan's rules for coverage of intraoral 
imaging have already been met. Therefore, we decided that the Plan does not have to pay for intraoral imaging 
(D0210) provided by a participating provider on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unlisted dental surgery procedure (41899) to be 
performed by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that due to a mental developmental delay, the 
enrollee is combative and does not cooperate for a complete and thorough medical exam. It is necessary that 
the requested provider perform this treatment as they have experience providing treatment to those with extra 
needs and the treatment required is extensive due to previous neglect. The Plan denied your request. The Plan 
says the requested services are not covered by the enrollee's dental 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. The record indicates that the enrollee requires treatment which is not 
covered by the Plan's dental benefit, including possible fillings/cavity treatments and/or treatment for severe 
periodontal disease. Therefore, we decided that the Plan does not have to pre-approve an unlisted dental 
surgery procedure (41899) to be performed by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve a complete upper and lower denture. You say that you accidentally threw 
out your old dentures and need new ones. The Plan denied your request. The Plan says you will exceed the 
frequency limit for the dentures. 
 
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 a complete 
upper and lower denture once every five plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper and 
lower denture were previously covered on January 15, 2021. Based on this information, we decided that the 
Plan's frequency limit for coverage of a complete upper and lower denture will be exceeded. Therefore, we 
decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Arestin subgingival powder. 
 
You asked the Plan to pre-approve the Arestin subgingival powder. You say that you would like 
reconsideration because the requested drug is medically necessary to treat the infection. The Plan denied your 
request. The Plan says this 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 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 pre-approve the 
Arestin subgingival powder.
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 enrollee does meet the inpatient rehabilitation 
admission criteria and her ongoing medical care warrants this level of care. The Plan denied your request. The 
Plan says the 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mesalamine capsules. 
 
You asked the Plan to pre-approve Mesalamine capsules. You say that the enrollee has tried two rounds of 
Prednisone and is still symptomatic. The Plan denied your request. The Plan says Mesalamine is a self-
administered drug and does not fall under Part B coverage. 
 
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 Mesalamine capsules.  
 
Benefits for Mesalamine capsules 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) provided on September 3, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for Automatic external defibrillator. You say that you have supplied the enrollee 
with a life saving device which they desperately needed. You have included a copy of the medical records to 
prove medical necessity. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 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 automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) provided on September 3, 2021 by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate tablets. 
 
You asked the Plan to pre-approve Methotrexate tablets. The Plan denied your request. The Plan says 
Methotrexate tablet is an oral self-administered drug. The Plan also says that this is not a buy and bill 
medication. 
 
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 Methotrexate tablets.  
 
Benefits for Methotrexate 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: 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 enrollee is stable and will require 
extended acute care in an LTACH. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require a transfer to an LTACH. 
 
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 available at the acute 
care hospital where they are currently receiving care. Our reviewer found that 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. The Plan has approved ongoing care in the current acute care facility. Our physician reviewer also found 
that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  
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: 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 enrollee does require medical supervision to 
determine the source of his extreme pain and his limited mobility. The Plan denied your request. The Plan says 
the criteria for an admission to the Acute Inpatient Rehabilitation setting have not been met. 
 
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 enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. Our 
reviewer found that at the current functional level, the enrollee does not need IRF therapies. While the enrollee 
may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation can be safely provided 
at a lower intensity and alternate 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 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: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the service is medically necessary. The Plan denied 
your request. The Plan says that the service is not medically necessary and does not meet coverage criteria. 
 
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.  
 
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 crown. Our reviewer says that the 
documentation provided meets the criteria for coverage for a crown for tooth #19. Our physician reviewer 
found a review of the enrollee's dental record and radiographs indicate that a core buildup (D2950) has been 
approved for tooth #19. This indicates that a significant portion of the tooth was compromised, and a crown 
restoration to restore the tooth to good masticatory function is reasonable and necessary. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown (D2740).  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the follow-up computed tomography (CT) scan (76830) and moderate 
sedation services (99152 and 99153) provided on August 17, 2021. 
 
You asked the Plan to pay for the follow-up CT scan and moderate sedation services.. You say that you would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says that CPT 
codes 76380, 99152 and 99153 have a status indicator of A and are considered bundled. 
 
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 denial rationale indicates that these codes have a status 
indicator of A on this physician fee schedule and are therefore considered bundled. CPT codes 76380, 99152 
and 99153 do have a status indicator of A on the physician fee schedule, but this means that they are considered 
active codes and are eligible to be paid separately. The Plan has not forwarded any additional rationale to 
indicate why these services are not payable. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the follow-up computed tomography (CT) scan (76830) and moderate 
sedation services (99152 and 99153) provided on August 17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for perfusionist services provided to the enrollee on November 
1, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these services are included in the facility claim. 
 
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 find that the denied codes are not supported in the medical record. Specifically, as the enrollee was 
inpatient, it was not appropriate to bill these services separately. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for perfusionist services provided to the enrollee on November 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency ambulance response with no transport provided 
on September 25, 2021. 
 
You asked the Plan to pay for emergency ambulance response with no transport. You say that this bill should 
be paid by the Plan. The Plan denied your request. The Plan says emergency ambulance response with no 
transport is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The records show you refused transport. The ambulance company did not provide 
transport services on September 25, 2021. The ambulance benefit is a transportation benefit. When there is no 
transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan 
does not have to pay for emergency ambulance response with no transport provided on September 25, 2021.