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

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says that the requested injection 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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is medically necessary. Our physician reviewer found that the last epidural steroid injection is noted on December 16, 2021. Another epidural steroid injection is medically 
reasonable and 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 an epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve recuperative care/medical respite. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is not clear what skilled services in the home setting are needed. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there are no documented skilled nursing or skilled therapy needs.  The recuperative care services 
requested, appear to be a combination of outpatient custodial care and social services. Such services are not 
covered under home health regulations and are not considered 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve recuperative care/medical respite.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT. You say that the enrollee needs additional PT visits. The Plan 
denied your request. The Plan says that there is not sufficient documentation to indicate that the services 
needed are of such complexity, or that the enrollee's condition can only be treated safely and effectively by a 
qualified therapist or under the supervision of a therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT. Our reviewer says that 
the 12 additional PT visits are medically reasonable and necessary. Our physician reviewer found that clinical 
documentation shows complexity of therapy required. Some long-term goals have been met, but not all 
appropriate goals have been met. Thus, the 12 additional physical therapy sessions are 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 PT have been met. Therefore, we decided that the Plan has to pre-
approve 12 additional physical therapy (PT) visits.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2751) provided on February 10, 2022. 
 
You asked the Plan to pay more for a crown. You say that you think the Plan used your 2022 benefits to cover 
this service which was 95% completed in 2021. The Plan denied your request. The Plan says your annual 
dental maximum amount has been met. 
 
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 record shows your annual 
maximum amount has been exhausted. Therefore, we decided that the Plan does not have to pay more for a 
crown (D2751) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the unspecified removable prosthodontic 
procedure, by report (D5899) provided on February 14, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit under your contractual policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the unspecified removable prosthodontic procedure, by report (D5899) provided on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on May 16, 
2021. 
 
You asked the Plan to pay for the hospital care. You say that your records indicate the claim was submitted 
timely. The Plan denied your request. The Plan says the claim was not filed within the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hospital care was not filed until May 20, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care (99232) provided on May 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 September 22, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from February 2, 2021, to February 3, 2021. 
 You asked the Plan to pay for the self-administered drugs. You say that you were advised you would only be 
responsible for the $365 copayment. You also say that it is not your responsibility to know how services should 
be billed. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs are not among the types which are covered by Medicare Part 
B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an 
outpatient setting from February 2, 2021, to February 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a lumbar interspinous process stabilization 
device without decompression or fusion (22869, 22870) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that research has not found this service to be helpful for the enrollee's 
condition or for what is causing the enrollee's pain. 
 
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 requested services are not considered medically reasonable and necessary in this case. This procedure has 
been reviewed by 2 learned societies of Orthopedics and was not endorsed. The procedure is not considered 
medically reasonable or necessary. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a lumbar interspinous process stabilization device without decompression or 
fusion (22869, 22870) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tele-health service (99442) provided on January 14, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the tele-health service. You say that most of your employees are sick. You say 
that it was not possible for you to get an authorization before the services were rendered. The Plan denied your 
request. The Plan says prior authorization was not obtained before the service was rendered to the enrollee. 
 
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 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 tele-health service (99442) provided on 
January 14, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis 
vaccine (Tdap) (90715), and administration (90471) provided on April 4, 2022. 
 
You asked the Plan to pay for the immunization. You say that you were told by the provider that the 
immunization is covered. You say that your pamphlet does not clearly stay that it needs to be administered at a 
pharmacy. You also say that you cannot afford unexpected expenses. The Plan denied your request. The Plan 
says the claim denied correctly. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715), and administration (90471) provided on April 4, 2022.  
 
Benefits for the immunization may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can't 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. You 
are medically stable and do not need physical medicine and rehabilitation physician's supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing needs identified or documented. At the current level of function, 
you do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week 
with a multidisciplinary approach in an IRF. There is no medical complexity. While you may benefit from 
continued physical and occupational therapy, your rehab needs can be safely provided in a lower intensity and 
alternate setting. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a crown (D2740) provided on February 7, 
2022, and a crown (D2740) and core build up (D2950) provided on March 2, 2022. 
 
You asked the Plan to reduce the cost share for crowns and core build up. You say that you were quoted a 
$1,000 payment for the first date of service and $500 for the second. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The 
contract with the Plan says that there is a $1,000 deductible which applies to crowns. The contract also says 
that enrollees must pay 50% coinsurance for in-network covered prosthodontic and prosthodontic maintenance 
services. The Plan contract also says that enrollees have a $1,000 coverage maximum for in-and out-of-network 
dental services. 
 
The enrollee has been asked to pay $557.13 for a crown received on February 7, 2022. The dental deductible 
was not met at the time of service; therefore, $100 was applied to satisfy the deductible. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is $100 deductible which applies to a crown. This cost sharing is a contractual obligation that had not been met at the time the crown was received on February 7, 
2022. 
 
The allowed amount remaining after the deductible was paid is $914.25 ($1,014.25 original allowed amount -
$100 deductible paid = $914.25 remaining allowed amount). The enrollee has been asked to pay $457.13, 
which is 50% coinsurance of the remaining allowed amount for a crown ($914.25 remaining allowed amount x 
50% coinsurance = $457.13).  
 
The enrollee has been asked to pay $507.13, which is 50% coinsurance for a crown received on March 2, 2022 
($1,014.25 allowed amount x 50% coinsurance = $507.13). The enrollee has also been asked to pay $250.24 
for the core build up received on March 2, 2022. The record shows the enrollee has met the maximum coverage 
amount during the processing for this claim. Crowns and core build up fall within the Dental Services benefit 
category. This means that the enrollee has been asked to pay the correct amount based on their contract with 
the Plan. This cost sharing is a contractual obligation they agreed to pay when they enrolled in the Plan. 
Therefore, we decided that the Plan does not have to reduce the cost share for a crown (D2740) provided on 
February 7, 2022, and a crown (D2740) and core build up (D2950) provided on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior, posterolateral or lateral transverse process 
technique arthrodesis procedures on the spine. 
 
You asked the Plan to pre-approve posterior, posterolateral or lateral transverse process technique arthrodesis 
procedures on the spine. You say that posterior, posterolateral or lateral transverse process technique 
arthrodesis procedures on the spine is medically necessary. The Plan denied your request. The Plan says 
posterior, posterolateral or lateral transverse process technique arthrodesis procedures on the spine is 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 posterior, posterolateral or lateral 
transverse process technique arthrodesis procedures on the spine. Our reviewer says that the posterior, 
posterolateral or lateral transverse process technique arthrodesis procedures on the spine is not considered 
medically reasonable and necessary. Our physician reviewer found that this procedure is considered an 
experimental procedure at this time. The request is deemed 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 posterior, posterolateral or lateral transverse process technique arthrodesis 
procedures on the spine have not been met. Therefore, we decided that the Plan does not have to pre-approve 
posterior, posterolateral or lateral transverse process technique arthrodesis procedures on the spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2750 x 10) and core build up (D2950 x 5) 
provided from September 27, 2021, to November 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were led to believe by the plan that you 
would be reimbursed up to $2,000. The Plan denied your request. The Plan says the dental services you 
received are not listed as covered. 
 
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 crown and core build up are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
crowns (D2750 x 10) and core build up (D2950 x 5) provided from September 27, 2021, to November 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service 
April 23, 2022, to May 20, 2022. 
 
You asked the Plan to pay for procedure code S9328. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service April 23, 2022, to May 20, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that SNF care is not medically necessary and there is no indication that the enrollee 
needs aggressive or complex therapy regimens. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does have documented skilled therapy needs and  a period of 
strength and endurance training is medically necessary and reasonable. Our physician reviewer also found that 
daily skilled services are required to establish a maintenance program and to prevent deterioration of the 
enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
  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.