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

 
We decided that the Plan does not have to pre-approve the periodic oral evaluation - established patient 
(D0120) and prophylaxis - adult (D1110) provided April 4, 2022. 
 
You asked the Plan to pre-approve the periodic oral exam and dental cleaning. You say that you don't 
understand why these claims are denied. The Plan denied your request. The Plan says these dental services are 
not covered under your plan. You may submit a Benefit Bank reimbursement request for possible 
reimbursement. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve 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 pre-approve the periodic oral 
evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided April 4, 2022.
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 LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH admission is not medically necessary. Our physician reviewer found the enrollee 
appears to be more stable and improving and should require only short-term additional acute care services that 
can safely be administered at the current facility until more stable and appropriate for a lower level of care. The 
enrollee does not require services at the LTACH that are not already available at the current facility. There are 
no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to LTACH is not medically necessary at this time as it would not be clinically advantageous. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on April 12, 2022, by an
out-of-network (OON) provider.
You asked the Plan to pay for a specialist office visit. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says there is no referral letter from an in-network physician, and the
services were not medically necessary. The Plan also says that there are in-network providers available.
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 a specialist office visit provided on April 12, 2022,
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on 
September 23, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible 
for this cost share. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Medicare-covered physical therapy visits.  
 
You have been asked to pay $20 for physical therapy. Physical therapy falls within the Outpatient 
Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for physical therapy provided on September 23, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due 
to insufficient evidence of efficacy. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
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 IRF care is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 
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 enrollee was admitted for thoracic fracture after a fall. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does 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. Medically necessary care can be provided in a 
different level of care. In conclusion, there is not a reasonable expectation that this 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that you are appealing the denied service. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because gingival 
irrigation 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 pre-approve 
gingival irrigation (D4921).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 13, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2394) provided on December 7, 
2021. 
 
You asked the Plan to pay for the resin-based composite. You say that you believe this service should be 
covered. 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 August 2, 2021. 
Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2394) provided on 
December 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric partial hospital care. 
 
You asked the Plan to pre-approve psychiatric partial hospital care. You say that psychiatric partial hospital 
care is medically necessary. The Plan denied your request. The Plan says psychiatric partial hospital care does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 psychiatric partial hospital care. Our 
reviewer says that psychiatric partial hospital care is not medically necessary. Our physician reviewer found 
that based upon review of the records provided, you were not showing any dangerousness to self or others and 
you have not been exhibiting severe psychological or psychiatric impairment requiring this level of care. You 
were not showing any perceptual disturbance, psychosis or aggressive behaviors. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the partial hospitalization level of care rather than 
a lower level of care as you did not have any suicidal or homicidal thoughts or behavioral disturbance and your 
symptomatology could be treated at a lower level of care. The health Plans denial of continued partial 
hospitalization treatment for the dates in question appears appropriate. You did not appear to require partial 
hospitalization treatment. You were not showing any severity of psychological or psychiatric illness. Based 
upon review the records provided, you do not meet the criteria for treatment at partial hospitalization level of 
care and could have been treated in a lesser restrictive setting as you were not showing any suicidal or 
homicidal ideation, and you were not showing any psychosis or aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychiatric partial hospital care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve psychiatric partial hospital care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an x-ray of the low back. 
 
You asked the Plan to pre-approve the back x-ray. You say that the enrollee has been in a great deal of pain and 
needs this imaging to determine the cause. The Plan denied your request. The Plan says there is no evidence 
that this testing has been ordered by your primary care provider. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. In this case, the Plan has requested an order and medical records 
from your primary care provider, and these have not been received. Without an order from the provider 
indicating that the tests are necessary, they cannot be approved. Based on this information, we decided that 
Medicare rules for coverage of the requested bone density testing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an x-ray of the low back.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested Intracept procedure is experimental. More research is needed before 
coverage can be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with accessories 
for the enrollee. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show a mobility limitation that impairs the ability to participate in one 
or more mobility-related activities of daily living. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the record 
from the providers does not indicate that the enrollee requires a motorized wheelchair to complete activities of 
daily living. He has sufficient upper body strength to manage a standard wheelchair for mobility-related 
activities of daily living. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 standard power wheelchair with accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost protein drinks, enteral formula, nutritionally 
complete (B4150) and enteral formula, nutritionally complete, calorically dense (B4152). 
 
You asked the Plan to pre-approve enteral formula. You say that you rely on the high calorie drinks in order to 
maintain your weight to live. You are unable to eat and swallow food enough to maintain your weight. You 
also say that the only other option is to have the feeding tube put back in, but that would be expensive and is 
something you do not want. The Plan denied your request. The Plan says you do not meet criteria for the 
requested enteral formula as you no longer have a feeding tube. 
 
The Plan must follow Medicare rules. The rules say that enteral nutrition is covered for a beneficiary who 
requires feedings via an enteral access device to provide sufficient nutrients to maintain weight and strength. 
 
While enteral nutrition may be appropriate in this case, neither the Plan nor Medicare offers coverage of these 
items. Specifically, enteral nutrition is covered for a beneficiary who requires feedings via an enteral access 
device. Therefore, we decided that the Plan does not have to pre-approve Boost protein drinks, enteral formula, 
nutritionally complete (B4150) and enteral formula, nutritionally complete, calorically dense (B4152).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reimplantation of a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the original system was damaged 
beyond repair. The Plan denied your request. The Plan says the enrollee did not demonstrate pain relief with a 
previously impacted electrode. 
 
The Plan follows Medicare rules. Medicare rules say that electrical nerve stimulators are only covered under 
certain medical indications.  
 
 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 requested services. Our physician 
reviewer found that not enough relief was obtained with the previous device. Therefore, the coverage criteria 
have not been met. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a reimplantation of a spinal cord stimulator.
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 needs acute rehabilitation. The Plan 
denied your request. The Plan says the requested IRF admission 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 provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that 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. Therefore, the reviewer found that the requested IRF 
admission is not medically reasonable or necessary. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on September 
22, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible 
for this cost share. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 for 
physical therapy.  
 
You have been asked to pay $20 for physical therapy. Physical therapy falls within the Outpatient 
Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for physical therapy provided on September 22, 
2021.