Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on March 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says the services 
were provided out-of-network and were not approved in advance. 
 
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 the outpatient visit provided on March 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft on tooth #10 (D7953) and the 
removal of impacted tooth #10 (D7240) provided on April 14, 2022. 
 
You asked the Plan to pay for a graft and removal of an impacted tooth. You say that you disagree with the 
denial of dental services. The Plan denied your request. The Plan says a bone replacement graft (D7953) and 
the removal of an impacted tooth (D7240) are not covered by 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. 
 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 a bone 
replacement graft on tooth #10 (D7953) and the removal of impacted tooth #10 (D7240) provided on April 14, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health visits. 
 
You asked the Plan to pre-approve additional home health visits. You say that additional home health is 
medically necessary. The Plan denied your request. The Plan says the records do not support the need for a 
skilled nurse to make more visits. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health visits. Our 
reviewer says that additional home health visits are not medically necessary. Our physician reviewer found the 
documentation doesnt support that the member requires additional skilled nursing services to provide 
treatment that is medically necessary. The member does not require additional skilled nursing  services to 
effectively provide treatment, care, and/or services in order to improve the members condition, perform a 
maintenance program to maintain the members condition and/or prevent deterioration.  The member has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  The 
requested home health services are not medically 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 additional home health visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional home health visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says based 
on the records medical necessity has not been shown. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with seizures requiring 
intubation, Ativan, Keppra, trach placement and percutaneous endoscopic gastrostomy placement. The enrollee 
required wound care for a sacral pressure wound. Recent notes describe the enrollee as undergoing weaning 
and now tolerating trach mask baseline. The enrollee appears to be more stable and improving and should only 
require 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 available at the current 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 the services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for D4341. We decided that the Plan does not have to pay for D4999, 
D1206, and D4381.  
 
You asked the Plan to pay for dental services (D4341, D4999, D1206, D4381).. You say that the enrollee will 
benefit from the requested dental services. The Plan says that these services are not covered. 
 
We decided that the Plan has to pay for D4341.  
 
The plan follows Medicare rules. 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 dental when the services are medically necessary and reasonable. 
 
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 for D4341 Our reviewer says that the record indicates 
severe periodontitis. The plan covers scaling and planing of one quadrant every 3 years. One unit of D4341 is 
recommended. 
 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 been met. Therefore, we decided that the Plan has to pay for 
D4341.  
 
We also decided that the Plan does not have to pay for D4999, D1206, and D4381. 
 
The plan follows Medicare rules. Medicare generally does not cover dental services. However, the Plan offers a 
dental benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request the test of the services. Our reviewer says that the 
remainder of the services are not covered by the plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of D4999, D1206, and D4381 have not been met. Therefore, we decided that the 
Plan does not have to pay for D4999, D1206, and D4381. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for allergy testing (code 95004) provided on March 14, 2022. 
 
You asked the Plan to pay for the allergy testing. You say that this allergy testing was medically necessary. The 
Plan denied your request. The Plan says the allergy testing (code 95004) that the patient had does not meet 
coverage criteria because there is no documentation of clinically significant allergic history or symptoms that 
were not controllable by empiric conservative therapy. There is no documentation of individualized selection of 
antigens based on specific details obtained and documented within the history and physical examination. 
 
The Plan follows Medicare rules. Medicare rules say that allergy testing is only covered when it correlates 
specifically to the patients history and physical findings, the test has proven efficacy demonstrated through scientifically valid medical studies published in peer-reviewed literature, and is performed on patients whose 
environment provides the reasonable probability of exposure to the specific antigen tested. 
 
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 allergy testing. Our reviewer says that 
the allergy testing provided does not meet Medicare's medical necessity criteria. Our physician reviewer found 
the record indicates that the enrollee has a history sinusitis and allergies. The record does not indicate the 
presence of significant allergy symptoms that have failed empiric treatment. The record does not indicate that 
testing was based upon whether the environment provides the reasonable probability of exposure to the specific 
antigen tested. 
 
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 allergy testing have not been met. Therefore, we decided that the Plan does 
not have to pay for allergy testing (code 95004) provided on March 14, 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 the admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's medical conditions per the records do not require the level of 
care provided at an IRF. The enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility or with home care or outpatient therapy services when appropriate. 
 
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 is currently at home bed bound for several years due to history with 
a cerebrovascular accident with left sided weakness and cellulitis. The enrollee requires assistance with 
dressing and is unable to perform walking due to the long period of immobility being bed bound. Per the 
physical therapy assessment on September 9, 2022, the enrollee is not appropriate for outpatient physical 
therapy. The complexity of the enrollee's nursing, medical and rehabilitation needs to not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy 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 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral imaging 
(D0220), and a resin-based composite (D2393), provided by a participating provider on January 19, 2022. 
 
You asked the Plan to pay for a limited oral evaluation, intraoral imaging, and a resin-based composite. You 
say that you thought this would be covered. The Plan denied your request. The Plan says the rendered dental 
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 a limited oral evaluation (D0140), intraoral imaging (D0220), and a resin-based composite (D2393), provided by a 
participating provider on January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder arthroscopy (procedure codes 29822, 29828) 
provided to the enrollee on June 17, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these codes should not be billed for other shoulder arthroscopy procedures billed on the same 
shoulder with the same date of service. 
 
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 the denied codes is: 
 
CPT 29822: 
 
Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral 
articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, 
articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign 
body[ies]) 
 
CPT 29828: 
 
Arthroscopy, shoulder, surgical; biceps tenodesis  
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report was not 
included in the documentation. Even so, if limited debridement or tenodesis was performed on the same 
shoulder as the primary arthroscopy procedure was performed, then these procedure would be inclusive to the 
primary procedure.  
 
We looked at this coder'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 pay for shoulder arthroscopy (procedure codes 29822, 29828) provided to the enrollee on June 17, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6740), a pontic (D6245), and an 
extraction (D7210), provided by a participating provider on April 14, 2022. 
 
You asked the Plan to pay for a retainer crown, a pontic, and an extraction. You say that you were unaware that 
you would be charged this much. The Plan denied your request. The Plan says these services have been 
correctly denied. 
 
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, D6740 and D6245 are not among those 
covered under this benefit. Two D7210 were provided on April 14, 2022. The first D7210 was covered and 
paid. The second D7210 has been denied due to frequency limitation. Therefore, we decided that the Plan does 
not have to pay for a retainer crown (D6740), a pontic (D6245), and an extraction (D7210), provided by a 
participating provider on April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing of 22+ classes (procedure code G0483) provided 
to the enrollee on January 25, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was sufficient information to manage the enrollee without definitive testing. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical record sent by the provider showed presumptive screening test results which are 
consistent with prescription medications, dosing schedules, or history and expected results. There was 
sufficient information to manage the member without definitive testing. The review has determined that the 
records did not demonstrate a need for drug testing of 22+ classes (procedure code G0483) provided to the 
enrollee on January 25, 2022. 
 
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 pay for drug testing of 22+ classes (procedure code G0483) provided to the enrollee on January 25, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) provided May 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that your provider was 
OON. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental cleaning (D1110) provided May 19, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950) provided by a 
participating provider on April 12, 2022. 
 
You asked the Plan to pay for a crown and a core build-up. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental 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 a crown 
(D2740) and a core build-up (D2950) provided by a participating provider on April 12, 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 enrollee has had 21 days of hospital 
stay and has failed to progress. The Plan denied your request. The Plan says the LTACH is not medically 
necessary, and the enrollee's medical needs are being met in the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with exacerbation of chronic obstructive pulmonary 
disease and congestive heart failure in the setting of Covid-19 infection. The record indicates that the enrollee 
continues to have acute care issues and still receiving acute care services in the current 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 long term acute care hospital (LTACH) services.