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 have complicated medical conditions and will 
need rehabilitation. The Plan denied your request. The Plan says you do not meet the requirements for 
approval. 
 
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 you were admitted for an infection of the right foot and had a below the knee 
amputation. Medical problems are stable. Our physician reviewer found there are no complex nursing or 
rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. 
 
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 pay for a surgical extraction on tooth # 20 (D7210) provided on 
November 10, 2021. 
 
You asked the Plan to pay for an extraction. You say that this service should be covered considering it was a 
simple tooth extraction. The Plan denied your request. The Plan says a surgical extraction (D7210) is not 
covered by your supplemental 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 you had a surgical extraction on tooth # 20 provided on November 10, 2021. 
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 a surgical 
extraction on tooth # 20 (D7210) provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation (D9222, D9223), therapeutic parenteral drug 
(D9610), an extraction on tooth #28 (D7210), bone replacement graft on tooth #28 (D7953), and unspecified 
preventive procedure (D1999) provided on December 2, 2021. 
 
You asked the Plan to pay for sedation, drugs, extraction, replacement graft, and preventive procedure. You say 
that you required oral surgery and these services should be covered as a medical claim. The Plan denied your 
request. The Plan says deep sedation (D9222, D9223), therapeutic parenteral drug (D9610), an extraction 
(D7210), bone replacement graft (D7953), and unspecified preventive procedure (D1999) are not covered by 
your routine 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 deep 
sedation (D9222, D9223), therapeutic parenteral drug (D9610), an extraction on tooth #28 (D7210), bone 
replacement graft on tooth #28 (D7953), and unspecified preventive procedure (D1999) provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to request reconsideration of the 
denied claim and continue seeing the same provider that you have been for the past 20 years. The Plan denied 
your request. The Plan says a review of the medical records shows that they do not support medical necessity 
for care with an OON. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior tibial neurostimulation services. 
 
You asked the Plan to pre-approve posterior tibial neurostimulation services. 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 follows Medicare rules. Medicare rules say that posterior tibial neurostimulation services are only 
covered for certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve posterior tibial neurostimulation 
services. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the enrollee has stress and urge incontinence. The urge 
incontinence is more bothersome. The enrollee had a trial of Mirabegron from October 2021 to January 2022 
without improvement. The documentation does not show that the enrollee has failed standard anticholinergic drug therapy or that the patient demonstrates intolerance to the anticholinergic drug therapy despite best 
attempts at management of the most common side effects of such therapy, such as dry mouth and constipation. 
As such, 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 posterior tibial neurostimulation services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve posterior tibial neurostimulation services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies do not show that this works better than other treatments or 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. more research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says no physician statement indicating the medical necessity for an inpatient rehabilitation 
admission is found, and no intake assessment from the facility is present. 
 
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 you are medically stable, and do not need physician supervision three times per week 
(at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing needs identified or documented. At the current functional level, 
you do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week 
with multidisciplinary approach in an IRF. Rehab needs can be safely provided in a lower intensity and 
alternate setting such as in a skilled nursing facility (SNF) with intermittent therapies or continued in-home 
therapies. 
 
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 admission to an inpatient rehabilitation facility (IRF).
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 enrollee's ongoing rehabilitative needs warrant an 
IRF level of care to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says the 
guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in 
another 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 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 below the knee amputation and was transferred to inpatient rehabilitation on May 11, 2022, 
then to skilled nursing on May 26, 2022. There is ongoing weakness and 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on December 7, 2021. 
 
You asked the Plan to pay for prophylaxis. You say that you should be reimbursed for the cleaning on 
November 7, 2021. 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 
prophylaxis (D1110) provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a periapical x-
ray (D0220) provided on December 23, 2020. 
 
You asked the Plan to pay for an evaluation and x-ray. You say that you are dissatisfied with the insurance 
company. The Plan denied your request. The Plan says this claim was submitted after the one year timely filing 
deadline. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an evaluation and x-ray was not filed until March 2, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a periapical x-ray 
(D0220) provided on December 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on December 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient surgery. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 outpatient surgery at issue in this appeal. The Plan did not pre-approve 
the outpatient surgery 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 outpatient surgery provided on 
December 30, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #6. 
 
You asked the Plan to pre-approve the crown. You say that tooth #6 has an old crown which needs to be 
removed, and you need a new bridge to be made for tooth #'s 6, 7, and 8. The Plan denied your request. The 
Plan says it is not medically necessary to replace the cap on your tooth. 
 
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 the 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 the crown. Our reviewer says that the 
documentation provided does not meet the criteria for coverage for a replacement crown (D2750) for tooth #6. 
Our physician reviewer found there is a crown present on tooth #6. There was no narrative as to why the crown 
needs replacement. Our reviewer also found that the x-rays do not show any recurrent caries or defects with the 
present crown. 
 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 the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth #6.
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 patient needs 24 hour assistance now and 
was independent prior to hospitalization. You also say that the family feels that he is not ready for independent 
care and requires additional inpatient care prior to discharge home. The Plan denied your request. The Plan 
says based on Medicare guidelines, the Skilled Nursing Facility (SNF) services you and/or your provider are 
requesting do not meet the requirements for approval.  
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 reviewer says that 
this does not meet criteria. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on January 23, 
2022. 
 
You asked the Plan to pay for critical care. You say that these services were billed by two separate providers at 
different times during the day for unrelated reasons. The Plan denied your request. The Plan says a National 
Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 36556 and 99291. This 
PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an 
appropriate modifier was not billed with this PTP code edit. This service was not billed appropriately by 
Medicare coding regulations. 
 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 99291 
is a column II code to column I code 36556. While these services were billed by two different providers, both 
providers have a primary taxonomy code of 207RC0200X  Internal Medicine Critical Care Medicine. 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 
critical care, first hour (99291) provided on January 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) and a guided tissue 
regeneration (D4266), provided by a participating provider on January 27, 2022. 
 
You asked the Plan to pay for a bone replacement graft and a guided tissue regeneration. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental 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 pay for a bone 
replacement graft (D7953) and a guided tissue regeneration (D4266), provided by a participating provider on 
January 27, 2022.
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 you are appealing with supporting 
records. The Plan denied your request. The Plan says based on Medicare guidelines, the Long-Term Acute Care 
Hospital (LTACH) services you are requesting 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan, and they have approved ongoing care in the 
current acute care setting. Our physician reviewer also found that 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.