Persius/hicric huggingface dataset:
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 this will give the enrollee the maximum 
opportunity of recovery and to assist with improving her outcome as her health has been significantly 
challenged. We foresee LTACH level of care as a benefit and a means to prevent multiple re-admissions and 
manage her ongoing medical complications. The Plan denied your request. The Plan says this is not medically 
necessary, and continued acute hospital stay was offered, until the member could discharge to a lower level of 
care. 
 
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 medical records do not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BluePrint, unlisted molecular pathology procedure (81479) 
provided March 18, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please reprocess this claim for payment at 
the in-network rate. The Plan denied your request. The Plan says this test is considered experimental and is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for BluePrint, unlisted molecular pathology procedure (81479) provided March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87500 billed for date of service December 8, 
2021. 
 
You asked the Plan to pay for procedure code 87500. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says they have agreed to pay for the 
other services; however, code 87500 is not supported as billed. 
 
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, the CPT Code Manual definition of 
code 87500 is infectious agent detection by nucleic acid; vancomycin resistance, amplified probe technique. 
 We asked our coder 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 procedure code 87500. Our reviewer says that the records 
provided do not support the billing of code 87500. Our reviewer found although CPT code 87500 is 
documented in the laboratory report, this procedure does not include documentation to show that this is a 
separate distinct service from CPT 87798, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87500 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87500 billed for date of service December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal exam (code D0180) you 
received on June 15, 2022. 
 
You asked the Plan to pay for code D0180. You say that there aren't any periodontists in your area, so your 
dentist referred you to this provider. You believe that your annual dental benefit should cover this service. The 
Plan denied your request. The Plan says this service is not covered under your dental 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. The Plan only covers the 
dental services specifically listed in your dental Schedule of Benefits.  Comprehensive periodontal exams (code 
D0180) are not listed as covered services. 
 
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 
comprehensive periodontal exam (code D0180) you received on June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 2, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the decision and request 
reconsideration because the doctor's office failed to send in a preauthorization form for approval. The Plan 
denied your request. The Plan says the out-of-network services were not authorized. 
 
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 laboratory services provided on June 2, 2022, by 
an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bronchoscopy (31622, 31623, 31624, 31628, 31629, 
31627, 31653) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a bronchoscopy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not emergent or urgent, and you do not need specialized 
services that are not available in the network. There are in-network providers that can provide this service. 
 
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 
a bronchoscopy (31622, 31623, 31624, 31628, 31629, 31627, 31653) to be provided by an out-of-network 
(OON) provider.
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 have been receiving home health services and 
have not progressed. You say you are concerned that you will decline and need hospitalization. The Plan 
denied your request. The Plan says the IRF care is not medically necessary, and your needs can be met at a 
lower level of care such as a skilled nursing facility (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 you have a past medical history of coronary artery disease, congestive heart failure, 
chronic obstructive pulmonary disease (COPD) and a current pressure ulcer. Your 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. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation 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 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 bitewings (D0274), intraoral imaging (D0230), and 
prophylaxis (D1110), provided by an out-of-network provider on March 10, 2022. 
 
You asked the Plan to pay for bitewings, intraoral imaging, and prophylaxis. You say that you believe the Plan 
should pay for this. The Plan denied your request. The Plan says the enrollee has not enrolled in the 
supplemental dental option. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for bitewings (D0274), intraoral 
imaging (D0230), and prophylaxis (D1110), provided by an out-of-network provider on March 10, 2022.
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 you would like to be able to attend the IRF since
they can get you back on your feet. The Plan denied your request. The Plan says you do not meet all the
required Medicare criteria for admission to an IRF.

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 your medical problems are stable and there are no complex nursing or rehabilitation
needs. While the medical record supports a need for physical or occupational therapy, there is no documented
need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polio virus vaccine (90713), administration (90471), 
Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715), and administration, each additional 
(90472) provided on March 1, 2022. 
 
You asked the Plan to pay for the immunizations. You say that the services denied as not covered. You say that 
the enrollee liability is limited to the amounts shown in the adjustments under group PR. You also say that 
medical records were provided for further processing. The Plan denied your request. The Plan says the services 
in this case are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunizations. 
The Plan follows the same rules.   
Records do not show that you have been injured or directly exposed to any illness related to the immunizations. 
Therefore, we decided that the Plan does not have to pay for the polio virus vaccine (90713), administration 
(90471), Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715), and administration, each 
additional (90472) provided on March 1, 2022.  
 
Benefits for the immunizations 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral - 
complete series of radiographic images (D0210) provided on May 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for the out-of-network 
liability for the dental services you received on May 25, 2022. You say that you received a bill from the 
provider, however you do not agree with the bill. The Plan denied your request. The Plan says the out-of-
network liability was applied correctly per your Plan 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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and 
intraoral - complete series of radiographic images (D0210) provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 11, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 an office visit provided on May 11, 2022, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110) provided on March 
31, 2022. 
 
You asked the Plan to pay for the dental services. You say that the previous dental provider did not make the 
dentures correctly causing them to be unusable. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 24, 2019. 
Therefore, we decided that the Plan does not have to pay for a complete denture - maxillary (D5110) provided 
on March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation 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 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 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation 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 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 oral hygiene instructions (D1330) provided by a participating 
provider May 26, 2022. 
 
You asked the Plan to pay for oral hygiene instructions. You say that x-rays should be covered. The Plan 
denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 oral 
hygiene instructions (D1330) provided by a participating provider on May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard hemi (low seat) wheelchair (K0002) 
replacement. 
 
You asked the Plan to pre-approve a standard hemi wheelchair replacement. You say that you do not agree with 
the denial. The Plan denied your request. The Plan says you were approved for a custom high strength ultra-
lightweight wheelchair on September 8, 2022. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you were approved for a custom high strength ultra-lightweight wheelchair with custom 
seating on September 8, 2022. A custom high strength ultra-lightweight wheelchair serves the same purpose as 
a standard hemi wheelchair replacement. Therefore, we decided that the Plan does not have to pre-approve a 
standard hemi (low seat) wheelchair (K0002) replacement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard  soft appliance, full arch (D9940) 
provided on March 12, 2022. 
 
You asked the Plan to pay for an occlusal guard  soft appliance, full arch (D9940). You say that you do not 
agree with the Plan by not wanting to disburse the money you invested for the dental work. You say that you 
have sent documentation and they have denied is on several occasions. The Plan denied your request. The Plan 
says the denial of authorization for this service is correct, because the occlusal guard is not covered by the Plan, 
 
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 an 
occlusal guard  soft appliance, full arch (D9940) provided on March 12, 2022.