Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210) and deep sedation/general 
anesthesia (D9222 and D9223). 
 
You asked the Plan to pre-approve the surgical extractions and deep sedation/general anesthesia. You say that 
you need to have multiple teeth removed and would like to be put to sleep for the procedure. The Plan denied 
your request. The Plan says these 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. The only type of extractions that are covered under your plan are 
simple extractions. Therefore, we decided that the Plan does not have to pre-approve surgical extractions 
(D7210) and deep sedation/general anesthesia (D9222 and D9223).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reimburse you for chiropractic manipulative treatment (98941) provided from 
March 23, 2020, through July 30, 2020. We decided that the Plan does not have to reimburse you for the new 
patient office or other outpatient visit (99203), diagnostic radiology (72082) and manual therapy techniques 
(97140) provided from March 23, 2020, through July 30, 2020. 
 
You asked the Plan to reimburse you for chiropractic treatment. The Plan says that claim number1308M00002 
was untimely as the claim was not filed within 180 days of the date of service. In addition, office exams, 
radiology services, and physical therapy rendered by chiropractors are not covered under Medicare Part C. The 
Plan is not liable for claims that are related to work injuries. 
 
We decided that the Plan has to reimburse you for chiropractic manipulative treatment (98941) 
provided from March 23, 2020, through July 30, 2020.  
 
The Plan must follow Medicare rules. The rules say that claims for services furnished on or after 
January 1, 2010 must be filed no later than one calendar year after the date of service. 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. 
 
We looked at the file and the Medicare rules. The file does not show that the claim was filed untimely per 
Medicare rules. Additionally, the Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny the chiropractic treatment. Specifically, the Plan has not provided 
any proof that a workmans compensation claim was filed, and that workmans compensation is responsible for 
payment. Therefore, we decided that the Plan has to reimburse you for chiropractic manipulative treatment 
(98941) provided from March 23, 2020, through July 30, 2020.  
 
We also decided that the Plan does not have to reimburse you for the new patient office or other 
outpatient visit (99203), diagnostic radiology (72082) and manual therapy techniques (97140) provided 
from March 23, 2020, through July 30, 2020. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
We looked at the file and the Medicare rules. The file shows that the services at issue are not manual 
manipulation of the spine. Therefore, we decided that the Plan does not have to reimburse you for the new 
patient office or other outpatient visit (99203), diagnostic radiology (72082) and manual therapy techniques 
(97140) provided from March 23, 2020, through July 30, 2020. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that you were told 
this would be covered. The Plan denied your request. The Plan says the requirements for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from April 29, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from April 29, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from April 
29, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of April 29, 2022, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond April 29, 2022, as he was not a danger to 
himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollee's condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from April 29, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from April 29, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the retreatment of previous root canal treatment 
(D3346). 
 
You asked the Plan to pre-approve the retreatment of previous root canal treatment. You say that this procedure 
is medically necessary. The Plan denied your request. The Plan says this service is not covered under the 
supplemental benefit package. 
 
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 
retreatment of previous root canal treatment (D3346).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical revision procedure (D4268) and bone 
replacement graft (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says these are not covered services. 
 
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 
surgical revision procedure (D4268) and bone replacement graft (D7953).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's condition, medical management and 
rehabilitation needs require an inpatient stay with close physician supervision. You say that the enrollee meets 
inpatient rehab criteria and is an excellent rehab candidate. The Plan denied your request. The Plan says acute 
inpatient rehabilitation 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 enrollee does not need close supervision 3 times per week and no rehab nursing 
needs were identified or documented in the record. The enrollee's rehab can be safely provided at a lower 
intensity and alternate 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services (99239) 
provided on October 19, 2021. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists 
between CPT code 99239 and 99221. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99239 
is a column II code to column I code 99221. A modifier is not allowed to bypass the edit in this case. Based on 
the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not 
have to pay for the hospital discharge day management services (99239) provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve contour next test strips. 
 
You asked the Plan to pre-approve contour next test strips. You say that the records provided should support 
the necessity of the item. The Plan denied your request. The Plan says the prior authorization requirements 
have not been met 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. The requested item has prior authorization requirements that 
have not been met. The Plan made several attempts to obtain the additional information from the provider 
without success. Based on this information, we decided that Medicare rules for coverage of contour next test 
strips have not been met. Therefore, we decided that the Plan does not have to pre-approve contour next test 
strips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 12 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve an additional 12 PT visits. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an additional 12 PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a 
therapist. There has been instruction in an independent home program, and you report you are competent in this 
home program. The requested services are not part of a maintenance program, and the specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 12 PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 12 physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the enrollee has 
suffered from this condition for over six years and has failed more than 6 months of conservative approaches to 
treatment. You say that you highly recommend this minimally invasive procedure when conservative treatment 
has failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. 
The Plan says this service is considered experimental and investigational. 
 
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 insertion of stabilization device 
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found interspinous process stabilization devices are 
experimental. More research is needed to show safety and efficacy. 
 
  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 insertion of stabilization device (22869) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON dialysis services. You say that the participating providers you 
have been referred to will not dialyze you at the nursing home. You say that the Plan will be forced to cover 
transportation fees in order to have you dialyzed 3 times a week. You say that you have a urinary catheter in 
place, have a diabetic ulceration on your left heel, and will require a wheelchair for transportation. You say that 
ambulating will increase your risk of losing your limb. The Plan denied your request. The Plan says there are 
network providers who can supply the care needed. 
 
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 items/services 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 
dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic and retainer crown rendered on January 28, 2022. 
 
You asked the Plan to pay for these services. You say that you didn't understand the coverage. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pontic 
and retainer crown rendered on January 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee requires 
transportation to treatment. The Plan denied your request. The Plan says that the beneficiary has exhausted this 
benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of thirty-six (36) trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
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 benefit from the 3-hour a day 
rehabilitation at the hospital. You state you would receive better care at the rehabilitation hospital where 
medical staff can attend to his issues. The Plan denied your request. The Plan says authorization denied because 
IRF care is not medically necessary, and your needs can be met at a lower level of care such as a SNF. 
 
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 medical problems are stable, and there are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy 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 pay for the dental implant placement you received on January 17, 2022. 
 
You asked the Plan to pay for the dental implant placement. You say that you would like to appeal this denial. 
The Plan denied your request. The Plan says dental implants are not covered for any reason. 
 
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's contract explicitly 
states that dental implants are not covered under any condition. Therefore, we decided that the Plan does not 
have to pay for the dental implant placement you received on January 17, 2022.