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

We decided that the Plan does not have to pre-approve hospital or ambulatory surgical center call (D9420) and 
services by an anesthesiologist (D9500). 
 
You asked the Plan to pre-approve dental services. You say that you need to have the tooth removed because 
you are in extreme pain. The Plan denied your request. The Plan says this service is not covered under your Plan. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Hospital or ambulatory 
surgical center call (D9420) and services by an anesthesiologist (D9500) are not covered under the Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested hospital or ambulatory 
surgical center call (D9420) and services by an anesthesiologist (D9500) are not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pre-approve hospital or ambulatory 
surgical center call and services by an anesthesiologist (D9500).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction of an erupted tooth requiring the removal 
of bone (D7210) for teeth numbers 2, 3, 4, 5, 14, and 15, deep sedation/general anesthesia (D9222, D9223), 
and therapeutic parenteral drugs (D9612), and the reduction of osseous tuberosity (D7485) for teeth numbers 
10 and 20. 
 
You asked the Plan to pre-approve the extraction of an erupted tooth requiring the removal of bone (D7210) for 
teeth numbers 2, 3, 4, 5, 14, and 15, deep sedation/general anesthesia (D9222, D9223), therapeutic parenteral 
drugs (D9612), and the reduction of osseous tuberosity (D7485) for teeth numbers 10 and 20. You say that you 
want to get all of this dental work in order for your mouth to be healthy. The Plan denied your request. The 
Plan says the requested services: sedation, surgical extractions, reduction of osseous tuberosity, therapeutic 
parenteral drugs are also not covered under the Plan 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 pre-approve the 
extraction of an erupted tooth requiring the removal of bone (D7210) for teeth numbers 2, 3, 4, 5, 14, and 15, 
deep sedation/general anesthesia (D9222, D9223), and therapeutic parenteral drugs (D9612), and the reduction 
of osseous tuberosity (D7485) for teeth numbers 10 and 20.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a partial denture (D5213) 
 
You asked the Plan to pre-approve the dental service. You say that you would like for this dental procedure to 
be covered. The Plan denied your request. The Plan says that the denial of authorization for this service is 
correct, because a partial denture is not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The request for authorization was on August 29, 2022, the Plan contract that was 
sent with the case file and that was requested was not the correct contract when the request for authorization 
was made. Therefore, we decided that the Plan has to pre-approve a partial denture (D5213)  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 1, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you believe this transportation 
should be approved for six weeks of therapy. The Plan denied your request. The Plan says 100 one-way trips 
are covered per calendar year, the 101st and beyond is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 100 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
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 a very complicated and 
prolonged hospitalization and the LTACH is medically necessary and is the most appropriate level of care. The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs are 
being met in the current acute care 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 recurrent diverticulitis requiring operative 
intervention. The record shows that the enrollee has had a complicated hospital course is improving and 
continues to have acute medical issues that require acute care management services. The medical record does 
not indicate that the enrollee requires services that he 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953) 
and a porcelain/ceramic crown (D2740). 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation (D7953) and a 
porcelain/ceramic crown (D2740). You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says Bone replacement grafts for ridge preservation (D7953) are not covered. The Plan 
also says that the enrollee exhausted the porcelain/ceramic crown (D2740) benefit on May 18, 2022, on teeth 
numbers 8 and 9. 
 
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 rules say that you 
may have two crown per year.  
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, bone replacement grafts for ridge 
preservation (D7953) are not among those covered under this benefit. Also, certain limitations apply to 
porcelain/ceramic crowns (D2740). The Plan rules say that you may receive two crowns per year. The record 
shows this benefit was exhausted on date of service May 18, 2022. Therefore, we decided that the Plan does 
not have to pre-approve bone replacement graft for ridge preservation (D7953) and a porcelain/ceramic crown 
(D2740).
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 disagree with the denial for admission to an IRF. 
The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 does not have complex nursing or rehabilitation needs. 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 pre-approve dental codes D6056 and D6058. 
 
You asked the Plan to pre-approve dental codes D6056 and D6058. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says dental codes D6056 and D6058 are not 
covered under the Plan's supplemental dental 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, dental codes D6056 and D6058 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental codes D6056 and D6058.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided with an outpatient hospital visit on 
February 23, 2022, billed with codes 84165, 85007, and 82607. 
 
You asked the Plan to pay for the lab testing. You say that this should be covered to allow for continuity of the 
enrollee's care. The Plan denied your request. The Plan says payment was approved for this claim; however, 
three of the codes at issue were paid to another provider and are considered duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 Codes 84165, 85007, and 82607 have a status indicator of "N" in the Outpatient Prospective Payment System. 
This means that they are packaged with payment for other billed services. Since payment was made for the 
claim, no separate payment is allowed for these three codes. Based on this information, we decided that 
Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab testing provided with an outpatient hospital visit on February 23, 2022, billed with codes 
84165, 85007, and 82607.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 24, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service provided was an evaluation and not 
an emergency. The Plan denied your request. The Plan says the 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 the dental 
services on May 2, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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 for a stroke. The enrollee's medical problems are stable, and 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy services provided from January 3, 2020, 
to December 23, 2020. 
 
You asked the Plan to pay for the massage therapy services. You say that the massage therapy keeps you from 
having to have spinal injections and back surgery. You also say that you would like the claims to be paid. The 
Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for the massage therapy services provided from January 3, 2020, 
to December 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you need to see the provider who is located 
353 miles away from you. You also say that you have seen local providers in your area, but they cannot treat 
you and are not familiar with your diagnosis. The Plan denied your request. The Plan says the benefit only 
allows 50 miles per one-way trip. The Plan also says that this request has exceeded the benefit limit. 
 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional transportation mileage.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee was not approved for SNF coverage, 
her progress has regressed. The enrollee needs strengthening exercises. The Plan denied your request. The Plan 
says the continuation of SNF care is not medically necessary, and the enrollee's needs can be met at a lower 
level of care. 
 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 there are no identifiable skilled nursing service needs that require skilled nursing 
services, including the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment. There are no identifiable skilled 
therapy service needs that require skilled therapy services, including the specialized skill, knowledge and 
judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable 
treatment. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical 
matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vivex Via allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Vivex Via allograft is considered 
experimental in nature for use in spinal surgery. More research is needed to support its safety and efficacy. The 
services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vivex Via allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the enrollee needs the seat elevator to 
allow him to transfer to his bed. He demonstrates the ability to use a slide board to transfer out of the chair and 
the ability to shift his weight while in the chair. The Plan denied your request. The Plan says durable medical 
equipment is covered if it is appropriate for use in the member's home. The seat elevation is not used to take 
care of a medical need. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300).
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. The Plan denied your request. The Plan says you do not require an 
intensive multidisciplinary approach to daily therapy. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for surgical management of a hip fracture after a fall. Your 
medical problems are stable. 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.