Persius/hicric huggingface dataset:
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not 
meet the requirements for approval. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. The Plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 dental implants provided by a participating provider. 
 
You asked the Plan to pre-approve dental implants. You say that these implants are needed to help with your 
speech. The Plan denied your request. The Plan says the requested dental 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 pre-approve 
dental implants provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that you have rotten teeth. You say that 
you need this denture. The Plan denied your request. The Plan says the requested services are not 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture (D5225) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an out-of-network provider. 
 
You asked the Plan to pre-approve dental services. You say that you would like the Plan to approve and pay for 
these services. The Plan denied your request. The Plan says covered dental benefits must be provided by a 
participating provider. 
 
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 
services when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pre-
approve dental services provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on February 1, 2022. 
 
You asked the Plan to pay for an x-ray. You say that you were unaware that the x-ray was not allowed again. 
The Plan denied your request. The Plan says this service is covered by your Plan's dental benefits; however, 
your benefit for one panoramic x-ray every three years has 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 covers one 
panoramic x-ray (D0330) every three years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a 
panoramic x-ray on October 11, 2021; therefore, the benefit for a panoramic x-ray has been exhausted. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on February 
1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions of tooth #12 through #14 (D7140) rendered by an 
out-of-network provider on March 1, 2022. 
 
You asked the Plan to pay for tooth extractions. You say that you were having trouble with your teeth and 
could not get an appointment within two to three months. You say you were unable to schedule an emergency 
appointment with anyone but the out-of-network provider and had already been treating infections prior to 
getting any work done. You say you would like to see the Plan reimburse you at 50% coinsurance for the dental 
work you received.  The Plan denied your request. The Plan says the denial was processed correctly. The Plan 
says preventive and comprehensive dental services offered through the Plan's supplemental dental benefit 
are only covered when received from an in-network provider. You did not receive prior authorization before 
services were provided.  
 
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. The Plan covers one tooth 
extraction per lifetime with a 50% coinsurance. However, services must be performed by an in-network 
provider in order to be a covered benefit. Prior authorization must be obtained to receive services from out-of-
network providers.   
 
We looked at the file, the Plan's rules, and Medicare's rules. Though the Plan offers a dental benefit in excess 
of Medicare coverage, the requested service is not covered under this benefit. While the service itself is usually 
covered by in-network dentists, you received dental services from an out-of-network provider without prior 
authorization from the Plan. Therefore, we decided that the Plan does not have to pay for extractions of tooth 
#12 through #14 (D7140) rendered by an out-of-network provider on March 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for a prostate biopsy 
procedure, a transrectal ultrasound, and a ceftriaxone sodium injection provided on October 29, 2021. 
 
You asked the Plan to waive the copayments and coinsurance for the biopsy, ultrasound, and injection. You say 
that you disagree with the charges. The Plan denied your request. The Plan says the correct copayments and 
coinsurance were applied. 
 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 $30 
copayment for specialist services, including surgical services performed in a physician's office. 
 
Your contract with the Plan also clearly says that you must pay a $105 copayment for diagnostic radiology 
services, including ultrasounds and a 20% coinsurance for medical supplies, including chemical agents used in 
certain diagnostic procedures. 
 
The file shows that the Plan removed the $42.13 copayment for the echo guidance. Therefore, you have been 
asked to pay a $30 copayment for the biopsy. The biopsy falls within the Physician/Practitioner Services, 
Including Doctor's Office Visits benefit category. You have also been asked to pay a $105 copayment for the 
ultrasound and $0.44 for the injection, which is 20% of the allowed amount ($2.24 allowed amount x 20% 
coinsurance = $0.44). The ultrasound and injection fall within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. The total for the visit is $135.44. 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 copayments and coinsurance for a prostate biopsy procedure, a transrectal ultrasound, and a ceftriaxone 
sodium injection provided on October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on November 7, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says one code 
must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the gene panel at issue was billed with multiple codes. If a single procedure is performed, only 
one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, 
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the gene panel provided on November 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the robotic surgical system provided on December 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that the code is a billable and payable code. The 
Plan denied your request. The Plan says the code is invalid for usage with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that CPT code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the robotic surgical system provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete radiographic imaging (D0210) provided by a 
participating provider on March 1, 2022. 
 
You asked the Plan to pay for a complete radiographic imaging. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the benefit limit for D0210 has already been met and 
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 covers a complete 
radiographic imaging once every five years.  
 
We looked at the file and Medicare rules. D0210 was previously provided on January 24, 2018. Based on this 
information, we decided that the Plan's rules for coverage of a complete radiographic imaging have not been 
met. Therefore, we decided that the Plan does not have to pay for a complete radiographic imaging (D0210) 
provided by a participating provider on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (D3331). 
 
You asked the Plan to pre-approve a root canal. You say that these services are medically necessary, and you 
disagree with the denial for dental services. The Plan denied your request. The Plan says a root canal (D3331) 
is 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 pre-approve a 
root canal (D3331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recementing crown on tooth #29 (D2920) provided on March 
9, 2022. 
 
You asked the Plan to pay for recementing crown. You say that you did not have the crown recemented. The 
Plan denied your request. The Plan says recementing crown (D2920) is not covered by the Plan's 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. 
 
The medical record shows tooth #29 had the crown recemented. 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 recementing crown on tooth #29 (D2920) 
provided on March 9, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that you are appealing this denia. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because these additional visits 
are not medically necessary. 
 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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you were receiving physical therapy and continuation of therapy is to 
promote safety/quality of life through participation to improve mobility. Additional visits 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 14 additional physical therapy visits.
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 you had a stroke and are unable to take care of 
yourself. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been 
met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve a crown. You say that you would like the Plan to approve and pay for this. 
The Plan denied your request. The Plan says services provided by an out-of-network provider are not 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. The Plan covers a crown when 
the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2750) provided by an out-of-network provider.
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 are appealing admission to IRF with medical 
records. The Plan denied your request. The Plan says the enrollee's documentation supports they cannot do 15 
hours of rehabilitation per week and a skilled nursing facility is suggested based on the enrollee's current 
medical needs. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne CDX genetic testing provided on September 29, 2021. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician determined that this 
testing was medically necessary. The Plan denied your request. The Plan says that the denial of payment for 
this testing is correct, because the enrollee did not meet the coverage criteria for next generation sequencing 
testing. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The record does not include prior notice from the Plan that this testing would not be 
covered. Without this information, we cannot determine whether the lab order made constituted plan-directed 
care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified 
according to Medicare rules. Therefore, we decided that the Plan has to pay for FoundationOne CDX genetic 
testing provided on September 29, 2021.  
 
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 for an intraoral x-ray (D0220) provided on December 2, 2021. 
 
You asked the Plan to pay for the intraoral x-ray. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 Plan's 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 an 
intraoral x-ray (D0220) provided on December 2, 2021.