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

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921), the unspecified periodontal 
procedure (D4999), the drugs dispensed for home use (D9630), the bone graft in conjunction with periradicular 
surgery (D3428), and the guided tissue generation (D3432) provided on June 7, 2022. 
 
You asked the Plan to pay for the gingival irrigation (D4921), the unspecified periodontal procedure (D4999), 
the drugs dispensed for home use (D9630), the bone graft in conjunction with periradicular surgery (D3428), 
and the guided tissue generation (D3432). You say that you cannot afford to pay for the non-covered services. 
The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation (D4921), the unspecified periodontal procedure (D4999), the drugs dispensed for home use 
(D9630), the bone graft in conjunction with periradicular surgery (D3428), and the guided tissue generation 
(D3432) provided on June 7, 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 recently had gallbladder surgery and developed 
infected fluid pocket. The Plan denied your request. The Plan says the request is not medically necessary, the 
services you need can be provided safely in other settings. 
 
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. There is no documented need for intensive rehabilitation services and 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig (A9282). 
 
You asked the Plan to pre-approve a wig. You say that it will help you mentally when in public places or at 
work while going through a difficult time in your life. The Plan denied your request. The Plan says the 
requested item is not covered by Medicare or the Plan because it is not considered medically necessary. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (A9282).
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the chemotherapy administration. We also decided 
that the Plan does not have to waive the coinsurance for the trastuzumab injection.  
 You asked the Plan to waive the coinsurance for chemotherapy infusion provided on February 16, 2022.. You 
say that you had the same services last year with no copayments. The Plan says that this cost sharing was 
charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the chemotherapy administration.  
 
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 does not clearly say that you must pay 
a 20% coinsurance for the chemotherapy administration. Therefore, we decided that the Plan has to waive the 
coinsurance for the chemotherapy administration.  
 
We also decided that the Plan does not have to waive the coinsurance for the trastuzumab injection. 
 
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% 
coinsurance for Medicare Part B prescription drugs. Therefore, we decided that the Plan does not have to waive 
the coinsurance for the trastuzumab injection. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 28, 
2022, to May 25, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no 
nursing services which would be considered skilled services by Medicare. 
 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from April 28, 2022, to May 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need these services to get stronger and recover 
from your injuries. 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 that 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic retainer crown (D6740) for teeth 
numbers 10 and 12, and a porcelain or ceramic pontic for tooth number 11 (D6245) provided on June 27, 2022. 
 
You asked the Plan to pay for a porcelain/ceramic retainer crown (D6740) for teeth numbers 10 and 12, and a 
porcelain or ceramic pontic for tooth number 11 (D6245). You say that you want to file an appeal for your 
tooth #10 that needs a cap. The Plan denied your request. The Plan says the services received are non-covered 
by Medicare. The Plan also says that there is no history that the enrollee or the office contacted the Plan prior 
to the above date of service to verify or discuss the enrollee's benefits for these 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. The Plan contract says that 
porcelain/ceramic retainer crowns (D6740), and porcelain or ceramic pontics are excluded from this benefit. 
 
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 
porcelain/ceramic retainer crown (D6740) for teeth numbers 10 and 12, and a porcelain or ceramic pontic for 
tooth number 11 (D6245) provided on June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PBRT 
 
You asked the Plan to pre-approve the PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical studies have not shown that PBRT is better than other treatments for this type of 
cancer. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient prospective, long-term clinical data available to determine whether or not 
proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation 
therapy, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
The most recent American Urological Association (AUA) guidelines state that PBRT offers no clinical 
advantage over other forms of definitive treatment.  
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 PBRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the PBRT
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a diagnostic colonoscopy provided on  
June 1, 2022. 
 
You asked the Plan to waive the deductible for a diagnostic colonoscopy. You say that your provider told you 
this would be covered 100%. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to a diagnostic colonoscopy.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to a diagnostic colonoscopy. This cost sharing is a contractual obligation that had not 
been met at the time a diagnostic colonoscopy was received on June 1, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for a diagnostic colonoscopy provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete services of intraoral radiographic images (D0210) 
provided on June 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were forced to find a new dental care clinic 
and doctor. You also say that because you were new to them, they needed to have a full examination, including 
x-rays to start with. 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. The Plan contract says that 
they cover the complete services of intraoral radiographic images (D0210) once every 36 months. 
 
 
  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 October 18, 2021. 
Therefore, we decided that the Plan does not have to pay for a complete services of intraoral radiographic 
images (D0210) provided on June 30, 2022.
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 SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information provided does not show that you need to have inpatient skilled nursing 
care for 4-6 hours per day or that you need to join in therapy services for 2 hours per day. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the limited documentation provided, the enrollee no longer qualifies for 
skilled nursing facility (SNF) services. A single occupational therapy record has been submitted for review. 
This record is insufficient to show that the enrollee has any skilled nursing or skilled therapy needs that would 
warrant this 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0651, E0667) provided to 
the enrollee on January 26, 2022. 
 
You asked the Plan to pay for the device. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation submitted did not contain a valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a pneumatic compression device 
(E0651, E0667) provided to the enrollee on January 26, 2022. have been met. The medical supplier did not 
provide a valid order to verify that the device was actually ordered by a physician. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0651, E0667) provided to the enrollee on 
January 26, 2022.
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 is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the criteria for admission to the LTACH have not been 
met. The enrollee's medical needs are being met in the current acute 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 medical records do not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility.  The elements of the coverage rules are 
not satisfied. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth (D7240). 
 
You asked the Plan to pre-approve removal of impacted tooth. You say that you are not able to get dentures 
until the two teeth are extracted. The Plan denied your request. The Plan says this service is not covered under 
your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
removal of impacted tooth (D7240).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is currently still in the hospital and needs 
physical therapy. The Plan denied your request. The Plan says based on Medicare guidelines, the inpatient 
rehabilitation facility services you are requesting do 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 the enrollee was admitted to an acute hospital on October 2, 2022, with confusion, 
seizures, and hypertensive crisis.  The enrollee was admitted with hypernatremia, hyperglycemia, dysphagia from altered mental status and 
metabolic encephalopathy. After a stay in ICU, the enrollee was extubated and stabilized and moved to a 
regular floor on October 7, 2022. There are no complex nursing or rehabilitation needs. While the enrollee has 
a need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care from 
March 30, 2022, to April 9, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility care. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged 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 $150 
copayment each day for days 1 to 100 for out-of-network SNF care.  
 
You have been asked to pay $1,500 for skilled nursing facility care. This item/service falls within the SNF care 
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 skilled nursing facility (SNF) 
care from March 30, 2022, to April 9, 2022.
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 is medically necessary for the 
enrollee. The Plan denied your request. The Plan says not medically necessary and the enrollees needs can be 
met at 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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.