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

We decided that the Plan does not have to pay for the complete denture (D5110), provided on July 8, 2021. 
 
You asked the Plan to pay for the complete denture. You say that the service should be covered. The Plan 
denied your request. The Plan says you have exhausted your Plan's maximum allowance for this benefit. 
 
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 the 
complete denture (D5110), provided on July 8, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be improving and is more stable only requiring additional 
short-term acute care services that can be safely administered at the current facility for now until able to 
discharge to a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested procedure is experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex device is experimental. More research is needed to show the safety 
and efficacy of the device. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be getting worse and is not stable or a good candidate for 
weaning at this time. The enrollee requires additional short-term acute care services that can be safely 
administered at the current facility. The enrollee does not require services at the LTACH that are not already 
available at the current 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on May 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that you are the only provider to provide this service 
and should be considered in-network. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
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 genetic testing provided on May 18, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablations (RFA). 
 
You asked the Plan to pre-approve RFA. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because only one 
diagnostic medial branch block was performed so the enrollee does not meet the criteria for radiofrequency 
ablation (RFA). 
 
The Plan follows Medicare rules. Medicare rules state that coverage of RFA is considered medically reasonable 
and necessary for patients who have had at least 2 diagnostic medial branch blocks. 
 
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 RFA. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested RFA procedure. Our physician reviewer found 
the enrollee has only received one lumbar diagnostic block in June 2020 and one cervical diagnostic block in 
September 2021. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablations (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scalings and root planings of four or more 
teeth per quadrant (D4341) on the upper right and lower right quadrants and periodontal scalings and root 
planings of one to three teeth per quadrant (D4342) on the upper left and lower left quadrants provided on June 
7, 2021. 
 
You asked the Plan to pay for the scalings and planings. You say that you needed these scalings and planings 
because your gums had become infected again, and you needed other dental work done that could not be 
provided without the root planing and scaling. The Plan denied your request. The Plan says your benefits for 
these services have been satisfied and the frequency limitation has been exceeded. 
 
 
 
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, scaling and root planing is limited to 
one procedure code every three years, per quadrant. The record shows that you received periodontal scalings 
and root planings of four or more teeth per quadrant (D4341) on the upper right and lower right quadrants and 
periodontal scalings and root planings of one to three teeth per quadrant (D4342) on the upper left and lower 
left quadrants on May 20, 2020, and your scaling and root planing benefits for all four quadrants has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal scalings and root 
planings of four or more teeth per quadrant (D4341) on the upper right and lower right quadrants and 
periodontal scalings and root planings of one to three teeth per quadrant (D4342) on the upper left and lower 
left quadrants provided on June 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion device (22869). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex Superion device. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a Vertiflex Superion 
device. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show 
it is safe and effective. 
 
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 insertion of a Vertiflex Superion device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion device (22869).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99211), provided on June 21, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this provider is not a network provider. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 an office visit (99211), provided on June 21, 2021 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on July 4, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the enrollee had no control 
over whether the provider would be out-of-network or not. The Plan denied your request. The Plan says the 
claims were processed correctly and the enrollee is being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $290 copayment for in-network and out-of-network ambulance services.  
 
The enrollee has been asked to pay a $290 copayment for ambulance services. Ambulance services fall within 
the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance services provided on July 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says you do not have 
an approved indication for the requested medication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Synvisc-One. Our physician reviewer 
found that you have bilateral shoulder osteoarthritis. You have limited ability raise your arms. You have tried 
steroid injections with only limited relief. The documentation does not support that the Synvisc-One is 
medically reasonable and necessary. It is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. The documentation does not support that the 
Synvisc-One is safe and effective for your 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and complete series x-ray (D0210) provided on June 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dental office claimed to be in network with 
your plan. You say that you received a bill for $400 because the dental practice is no longer in network. The 
Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that 
dental services received out of network 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the oral evaluation, prophylaxis, and x-
ray are not among those covered under this benefit when you receive them out of network. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and complete series x-ray (D0210) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on February 24, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed for medical 
necessity. The Plan denied your request. The Plan says payment for this pre-operative visit was included in the 
payment for the surgical procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, there were no medical records provided in this case. 
Without the medical records, we cannot review to see if the services were billed correctly in this case. 
Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on February 24, 
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on June 17, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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. The 
records provided for review do not show that the service at issue was urgent or emergent.  
Therefore, we decided that the Plan does not have to pay for the drug testing provided on June 17, 2021, 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. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not require, nor could you actively participate in three hours per day, 
five days per week of intensive 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the provided documentation indicates that the enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The reviewer found that the enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The reviewer found there is no documented need for a intensive, multi-
disciplinary rehabilitation program. Therefore, the reviewer found there is not a reasonable expectation that the 
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. Specifically, the file does not show there is a 
documented need for a intensive, multi-disciplinary rehabilitation program. Therefore, we decided that the Plan 
does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 home health speech therapy visits. 
 
You asked the Plan to pre-approve home health speech therapy visits.. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health speech therapy visits.. Our 
reviewer says that the documentation does not support that the Our physician reviewer found the enrollee does 
not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to 
improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or 
prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. The enrollee has received previous speech therapy for education and 
training and should be independent with the skills taught by the speech therapist. Therefore, the enrollee does 
not meet criteria for the requested 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 home health speech therapy visits. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 home health speech therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee will be frail until she heals from 
surgery. The Plan denied your request. The Plan says the enrollee has no skilled medical needs and does not 
need daily inpatient skilled therapy. 
 
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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral and inhaled medications, had stable vital signs, 
and was treated for pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation 
services, the enrollee was at a standby assist level with functional mobility. She required varying assist with 
activities of daily living. Although there are identifiable skilled therapy service needs, she does not require 
skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.