Persius/hicric huggingface dataset:
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 would benefit from IRF care to improve your 
strength with the use of skilled therapeutic exercise intervention, wound healing through skilled wound 
management, mobility through home management training, and mobility and safe discharge through skilled 
patient and caregiver education. You say that you are capable of actively participating in the therapy 
requirements of inpatient rehabilitation. You say that you need the complex interdisciplinary team approach 
that can only be obtained through inpatient rehabilitation. The Plan denied your request. The Plan says IRF care 
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 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 thoracolumbar spine surgery. The enrollee's 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardioversion rendered on September 10, 2021. 
 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 procedure code 92960 is not separately payable. 
 
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 92960 
is a column II code to column I code 93656. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the cardioversion rendered on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for complete upper dentures (D5110) and implant supported lower 
dentures (D3250) provided on February 8, 2022. 
 
You asked the Plan to pay for the dentures. You say that this the is first time you have used your dental 
coverage since having this insurance. The Plan denied your request. The Plan says that you have exceeded your 
$2,000 maximum dental allowance. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide the current Evidence of Coverage (EOC) for 2022. 
Without the correct EOC we are unable to determine if you exceeded the maximum dental allowance for 2022. 
Therefore, we decided that the Plan has to pay for complete upper dentures (D5110) and implant supported 
lower dentures (D3250) provided on February 8, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a suction-assisted lower extremity lipectomy. 
 
You asked the Plan to pre-approve the lipectomy procedure. You say that this is medically necessary for your 
condition. The Plan denied your request. The Plan says this is not considered a medically necessary 
reconstructive surgery. 
 
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 lipectomy procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 77-year-old woman with bilateral primary osteoarthritis of the knees, 
as well as diabetes, obesity based on her height and weight, and uterine cancer. The enrollee reported that the 
heaviness/swelling in her legs make it difficult for her to walk and has caused her to fall more often. The 
enrollee has not tried any decongestive or compression therapy for her legs. Physical examination revealed 
significant excessive adipose tissue in both legs, from the mid thighs to the ankles. There were no rashes, 
significant lesion, petechiae, or bruising. The enrollee was diagnosed with dermatolipodystrophy of the 
bilateral lower extremities, as well as upper extremities. The case file does not contain photographs of the 
enrollee's condition.  
The documentation does not support that suction assisted lower extremity lipectomy is medically reasonable 
and necessary for the enrollee in this case. The documentation does not support that the proposed lipectomy 
meets, but does not exceed, the enrollee's medical need, and that the procedure is at least as beneficial as any 
existing and available medically appropriate alternative. 
 
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 lipectomy procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a suction-assisted lower extremity lipectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment (D8090). 
 
You asked the Plan to pre-approve the comprehensive orthodontic treatment. 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 pre-approve 
comprehensive orthodontic treatment (D8090).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a labial veneer (D2961) 
 
You asked the Plan to pre-approve the labial veneer. 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 pre-approve a 
labial veneer (D2961)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first periapical x-ray (D0220), the additional periapical x-
ray (D0230), the bitewing x-rays (D0272), and the limited oral evaluation (D0140) provided by an out-of-
network provider on March 22, 2022. 
 
You asked the Plan to pay for the first periapical x-ray (D0220), the additional periapical x-ray (D0230), the 
bitewing x-rays (D0272), and the limited oral evaluation (D0140). You say that you set up the appointment to 
get an opinion about a filling, but was told that without an x-ray, the dentist cannot do it. You say this cost you 
over $200. The Plan denied your request. The Plan says the services are not covered benefits and the claim was 
paid correctly. 
 
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 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 50% 
coinsurance for out-of-network bitewing x-rays, including any amount greater than the payment made by the 
Plan to the provider. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, first periapical x-ray (D0220), the 
additional periapical x-ray (D0230), and the limited oral evaluation (D0140) are not among those covered 
under this benefit.  
 
You have been asked to pay $7.50 which is 50% of the allowed amount for the bitewing x-rays (D0272). The 
allowed amount is $15. ($15 x 50% = $7.50). The record shows the provider charge was $50. The difference 
between the provider charge and the allowed amount is $35. ($50 - $15 = $35). You are also responsible for 
this amount.  
 
Therefore, we decided that the Plan does not have to pay for the first periapical x-ray (D0220), the additional 
periapical x-ray (D0230), the bitewing x-rays (D0272), and the limited oral evaluation (D0140) provided by an 
out-of-network provider on March 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on June 9, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance services were medically 
necessary. The Plan denied your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the documentation 
does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other 
type of vehicle) were contraindicated for the enrollee. The reviewer found that the enrollee was in stable 
condition and required no basic life services (BLS) or advanced life services (ALS) services during transport. 
Therefore, the reviewer found that the ambulance services were 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 the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and 
ground mileage (A0425) provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #8. 
 
You asked the Plan to pre-approve a crown. You say that you are on a limited income. The Plan denied your 
request. The Plan says the records do not show a cavity or fracture affecting chewing or exposing the tooth 
underneath. 
 
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 a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that a 
crown (D2740) for tooth #8 is not medically necessary. Our physician reviewer found the provided x-rays do 
not show any defects around the crown. Our reviewer found that there are no clinical notes to review that 
would indicate any defect with the existing crown. In this instance there is no clear defect around the crown on 
x-ray, and no clinical documentation to support the crown being defective or has a compromised margin. Our 
physician reviewer also found that given the lack of support for the crown being defective, there can be no 
necessity for a replacement crown at this time. 
 
We looked at this physician's review, 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 (D2740) for tooth #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180), 
crowns (D2740 x 2), core build up (D2950 x 2), and givgivectomy (D4212 x 2). 
 
You asked the Plan to pre-approve an evaluation, crowns, core build up, and givgivectomy. You say that you 
were told that you had coverage for dental work. The Plan denied your request. The Plan says a comprehensive 
periodontal evaluation (D0180), crowns, (D2740), core build up (D2950), and givgivectomy (D4212) are 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 
comprehensive periodontal evaluation (D0180), crowns (D2740 x 2), core build up (D2950 x 2), and 
givgivectomy (D4212 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950). 
 
You asked the Plan to pre-approve core build up. You say that this service should be covered since you are not 
over your yearly maximum amount. The Plan denied your request. The Plan says core build up (D2950) 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 core 
build up (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulpal debridement (D33221) and periapical x-ray 
(D0220) provided on January 11, 2021. 
 
You asked the Plan to pay for the dental services. You say that your plan switched your dental coverage 
without telling you. You say that this type of x-ray was covered in 2020. You also say that you were not 
informed that the coverage had changed for 2021. The Plan denied your request. The Plan says the claim 
denied correctly. 
 
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 pulpal debridement and periapical 
x-ray are not among those covered under this benefit. Additionally, the record shows that the Annual Notice of 
Changes (ANOC) for 2021 was sent to you on September 21, 2020. Therefore, we decided that the Plan does 
not have to pay for the pulpal debridement (D33221) and periapical x-ray (D0220) provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incomplete endodontic therapy (D3332) and cone beam 
imaging (D0364) provided on November 8, 2021. 
 
You asked the Plan to pay for endodontic therapy and imaging. You say that you were not aware when the 
services took place that the provider was opted out of Medicare. The Plan denied your request. The Plan says 
this provider has opted out of Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
incomplete endodontic therapy (D3332) and cone beam imaging (D0364) provided on November 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from June 30, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from June 30, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from June 30, 
2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of June 30, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond June 30, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from June 30, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from June 30, 2022, 
forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services provided on September 28, 2021. 
 
You asked the Plan to pay for the services provided. You say that the debridement should be payable 
separately. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
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 11042 is a column II code to column I code 11044. 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 the debridement 
services provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on February 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 a home health visit provided on February 16, 
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 office visit coded 99213 provided on December 22, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not payable. 
 
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 99213 is not supported in the medical record. Specifically, evaluation and management 
codes are not covered for this specialty/provider type. This means this claim is not payable as billed. Based on 
this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, 
we decided that the Plan does not have to pay for the office visit coded 99213 provided on December 22, 2021.