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

 
We decided that the Plan does not have to pre-approve a crown (D2750) and endodontic therapy (D3320). 
 
You asked the Plan to pre-approve the crown and endodontic therapy. The Plan denied your request. The Plan 
says these services are not covered under the enrollee's benefit plan. 
 
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 
crown (D2750) and endodontic therapy (D3320).
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. The Plan denied your request. The Plan says the enrollee's safe 
discharge plan has been developed and recommended and will discharge home with family. Home health 
services are being recommended upon discharge. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial of admission. The Plan 
denied your request. The Plan says the service requested is not supported based on the records received.  
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 from a nursing perspective the enrollee received enteral nutrition and medications 
and had vital signs. The enrollee also received wound care to his sacrum and multiple other areas. He also 
required total assist with functional mobility and activities of daily living skills. The enrollee does have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. Our reviewer also found that the enrollee does not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral exam and cleaning to be rendered by an out-of-
network provider. 
 
You asked the Plan to pre-approve the oral exam and cleaning. You say that you have been going to the 
requested out-of-network dentist for a very long time, and you do not want to change. The Plan denied your 
request. The Plan says dental services from an out-of-network provider are not covered by your supplemental 
benefits. The Plan also says your needs can be met in-network, and going out-of-network is not medically 
necessary at this time. 
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve an oral 
exam and cleaning to be rendered by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on October 5, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you had a routine dental cleaning, and it should 
be covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the periodontal maintenance is not covered by the Plan. 
 
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 
periodontal maintenance (D4910) provided on October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that are 
requesting a reconsideration. The Plan denied your request. The Plan says the enrollee does not require insulin 
three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic continuous glucose monitor (CGM).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 documentation shows that you have functional impairments however no complex 
functional deficits or active medical issues have been specified thus the complexity of your documented 
nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. Additionally, evaluating therapists recommend a skilled 
nursing facility after discharge thus you would not be expected to tolerate 15 hours of therapy per week. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Carpal Tunnel surgery, to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Carpal Tunnel surgery. You say that the service is medically necessary. The 
Plan denied your request. The Plan says there are in-network providers available to perform this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the Carpal Tunnel surgery, to be provided by an out-of-network (OON) provider.
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 the enrollee's 
participation has been limited due to multiple factors, and it is not clear the enrollee would be able to tolerate 
the intensity of therapies provided in the IRF setting. 
 
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 documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on August 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that post-operative services are included in the global 
surgical package.  
 
We looked at the file and Medicare rules. Procedure code 99213 was related to and billed within 10 days of 
minor surgical procedure 11750 billed for August 1, 2022. Payment for code 99213 is included in the global 
surgical package. Therefore, we decided that the Plan does not have to pay for the office visit rendered on 
August 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 14, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  
 
 
 
 
 Therefore, we decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) 
of service July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that you are 
appealing the denial. The Plan denied your request. The Plan says the enrollee does not require insulin three or 
more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left lower extremity angiography and 
revascularization (37220, 37221, 37224, 37227, 37228, 37229). 
 
You asked the Plan to pre-approve a left lower extremity angiography and revascularization. You say that these 
services are medically necessary. The Plan denied your request. The Plan says these 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 a left lower extremity angiography and 
revascularization. Our reviewer says that there is insufficient documentation to support the medical necessity 
for left lower extremity angiography and revascularization in this patients clinical management. Our physician 
reviewer found while the patient has a history of peripheral vascular disease, with previous percutaneous 
intervention in the right leg, the documentation does not confirm the presence of severe disease in the left leg, 
Moreover, medical therapy has not been maximized. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a left lower extremity angiography and revascularization have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a left lower extremity angiography and 
revascularization (37220, 37221, 37224, 37227, 37228, 37229).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). The Plan denied your 
request. The Plan says the enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their 
CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for 
coverage of the therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99254 billed for date of service July 25, 
2022. 
 
You asked the Plan to pay for procedure code 99254. You say that you want to appeal this denial. 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 99254 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99254 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99254 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99254 billed for date of service July 25, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from May 30, 2022, to June 28, 
2022. 
 
You asked the Plan to pay for home health services. You say that the NOA was submitted. The Plan denied 
your request. The Plan says that the claim has not been billed with the correct admission date. 
 
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. 
 
We looked at the file and the rules. The Plan has not provided the submitted NOA to show that the admission 
dates on the NOA and claim at issue do not match. The Plan has not made reasonable and diligent efforts to 
gather and forward to us information regarding their decision to deny your request.  Therefore, we decided that 
the Plan has to pay for the home health services provided from May 30, 2022, to June 28, 2022.  
 
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 pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary. The Plan 
denied your request. The Plan says the SNF care is not medically necessary, and the enrollee signed a NOMNC 
(Notice of Medicare Non-Coverage) advising services would be terminated. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 pre-approve skilled nursing facility (SNF) care.