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

 
We decided that the Plan does not have to pay for the dental services provided on November 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says you have reached your $1500 annual 
maximum benefit for dental 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. 
 
We looked at the file, the Plan's contract, and Medicare rules. The Plan's contract clearly says there is a $1500 
annual maximum benefit allowance. The file shows that you had already reached your $1500 maximum 
allowance and you are responsible for these charges. Therefore, we decided that the Plan does not have to pay 
for the dental services provided on November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sublocade. 
 
You asked the Plan to pre-approve Sublocade. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is not covered under the patient's medical benefits. 
 
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 Sublocade.  
 
Benefits for Sublocade 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets criteria for an IRF admission. The 
Plan denied your request. The Plan says based on Medicare guidelines, your request for an IRF admission does 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. 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. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
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 will not be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. You continue to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that you would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status. You can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) intraoral - periapical 
each additional x-ray provided September 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that though this was not a regular visit and you were 
not an established patient at the time, this visit should be covered as a regular visit and not a limited oral 
evaluation. The Plan denied your request. The Plan says these services are not covered benefits or exceeds the 
Plan's maximum allowed. 
 
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. In this case the limited oral 
exam is not listed a covered dental service in the Description of Benefit. Intraoral x-rays are covered one procedure per calendar year. The records show that this benefit was paid for CPT code D0220 for this same 
date of service.  
 
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 or exceeds the maximum frequency allowed. Therefore, we decided 
that the Plan does not have to pay for the limited oral evaluation (D0140) intraoral - periapical each additional 
x-ray provided September 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from July 14, 2021, 
to September 10, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you were not aware of the timely 
filing requirement for initial RAP for the claim to be paid with the Plan. The Plan denied your request. The 
Plan says the initial RAP claim was not received within 5 calendar days from the start of care. The Plan also 
says that the RAP claim was not submitted until October 7, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date, July 14, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health care services provided from July 14, 2021, to September 10, 
2021.
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 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on 
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) 
following a stroke.  The enrollee was intubated/ventilated and subsequently received a tracheotomy and feeding 
tube. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and 
ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the 
LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided November 23, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that the exam and evaluation were 
appropriate and medically necessary. The Plan denied your request. The Plan says you have exceeded the 
frequency limit for this service. 
 
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 
comprehensive oral exam once every three plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on May 10, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided November 23, 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 there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that he would meet criteria for admission 
to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain his functional status. The enrollee can receive further services 
at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the dental services provided on February 27, 2020. 
 
You asked the Plan to pay additionally for the dental services. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says for date of service February 27, 2020, 
you were reimbursed the maximum amount of $300 for the dental services you received. For the 2021 benefit 
year, the Plan has decided to reimburse you additionally for the dental services you received on January 16, 
2021, totaling $95, leaving a remaining balance of $205 for the 2021 benefit year. 
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. 
 
We looked at the file, the Plan's contract, and Medicare rules. The Plan contract clearly states there is a $300 
maximum allowance for dental services every year. In this case, the file shows that the Plan reimbursed you the 
maximum amount of $300 for the dental services you received on February 27, 2020. You are responsible for 
any amount over this $300 maximum amount for non-Medicare covered dental services received in 2020. 
Additionally, the Plan decided to reimburse the remaining $50 balance for the dental services you received on 
January 16, 2021, leaving you with $205 still remaining for dental services received in 2021. Therefore, we 
decided that the Plan does not have to pay additionally for the dental services provided on February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on October 31, 2021, 
through November 6, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the DRG billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 with primary diagnosis code A41.9. We 
asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services. Our reviewer 
says that the documentation supported an admission for aspiration pneumonia. From the information that was 
received, documentation was unclear regarding a diagnosis of sepsis. Even though sepsis is documented on the 
history and physical, supporting medical record documentation was not found within the record. After further 
ER eval patient was admitted for pneumonia, hypotension, and AKI. There was no clinical or laboratory 
evidence of sepsis. Our physician reviewer found the documentation did not support the diagnosis code of 
A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on October 31, 2021, through November 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed. The 
Plan denied your request. The Plan says these 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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on October 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you did not require skilled therapy 
to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled 
services on an inpatient basis, at a SNF level of care as of 4/13/22. You did not have any parental medications, 
complex wound care or nutrition given via a feeding tube. You received skilled care and improved; however, 
your functional improvement had plateaued, and you did not require any further inpatient skilled rehab 
services. Your function was at or near your prior level of function and you could be discharged to a lower level 
of care for further services. As of 4/13/22, you required custodial services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infuse BMP-2 Allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Infuse BMP-2 Allograft 
in the setting of posterolateral lumbar spine fusion surgery has not been demonstrated in the peer-reviewed 
literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Infuse BMP-2 Allograft for the enrollee.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the treatment of the finger fracture (26720) provided on June 17, 2021. 
 
You asked the Plan to pay for the treatment of the finger fracture. You say that you would like reconsideration 
because this service was not bundled. The Plan denied your request. The Plan says that the modifier billed is 
not correct. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 26720 is supported in the record. Specifically, the documentation supports that this 
service was used to explain that the surgeon performed the surgical procedure only and relinquished  a part or 
all of the postoperative days to another physician. The Plan has not forwarded any explanation or evidence as 
to why the modifier billed is not correct. 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. Based on this 
information, we decided that Medicare rules for coverage of the treatment of the finger fracture have been met. 
Therefore, we decided that the Plan has to pay for the treatment of the finger fracture (26720) provided on June 
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.