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

 
We decided that the Plan has to pre-approve retainer crowns (D6740) for tooth #'s 27, 30, 19, and 22 and 
pontics (D6245) for tooth #'s 28, 29, 20, and 21. 
 
You asked the Plan to pre-approve the retainer crowns and pontics. You say that you had periodontal disease. 
The Plan denied your request. The Plan says that for this service to be approved you must only be missing 1 
tooth in this part of your mouth. The Plan also says that the records show that you are missing more than 1 
tooth in this part of your mouth and this service will not restore function of your mouth correctly. 
 
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 a copy of the applicable 2022 Evidence of Coverage or 
the Dental Plan Clinical Criteria for this case. We asked for the 2022 Evidence of Coverage, but it was not 
provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial 
of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and 
benefits. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we 
decided that the Plan has to pre-approve retainer crowns (D6740) for tooth #'s 27, 30, 19, and 22 and pontics 
(D6245) for tooth #'s 28, 29, 20, and 21.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rubber dam (D3910), and fitting and placing post in a 
tooth (D3950). 
 
You asked the Plan to pre-approve the rubber dam and fitting and placing post in a tooth. You say that the 
services are necessary. The Plan denied your request. The Plan says rubber dam is not listed as a covered 
service. The Plan also says that fitting and placing post in a tooth is not listed as a covered service either. 
 
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 rubber dam and fitting 
and placing post in a tooth are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve rubber dam (D3910), and fitting and placing post in a tooth (D3950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (D6011) for teeth # 5 
and 13. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says surgical access to an implant body is not listed as a covered service. 
 
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 surgical access to an 
implant body for teeth # 5 and 13 are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve surgical access to an implant body (D6011) for teeth # 5 and 13.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided on August 9, 2021. 
 
You asked the Plan to pay for psychotherapy. You say that the medical records prove medical necessity, and 
the claim should be processed toward payment. The Plan denied your request. The Plan says that there was no 
documented contact with the attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have been met. Specifically, the record shows that the enrollee was referred to this 
provider by a primary physician. Therefore, we decided that the Plan has to pay for psychotherapy provided on 
August 9, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J2001 billed for date of service December 1, 
2021. 
  You asked the Plan to pay for procedure code J2001. The Plan denied your request. The Plan says payment for 
code J2001 is bundled into payment for code 20611. 
 
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 J2001 
is a column II code to column I code 20611. 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 J2001 billed for date of service December 1, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0554).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex placement procedure (22867, 22868). 
 
You asked the Plan to pre-approve a Coflex placement procedure. You say that the requested services are a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested services are 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 Coflex placement procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the Coflex procedure is experimental. More research is needed to 
demonstrate the safety and efficacy of the procedure. 
 
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 Coflex placement procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Coflex placement procedure (22867, 22868).  
 Your complaint about receiving erroneous or misleading information about your benefits from a representative 
of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a humidifier, heated, used with a positive airway 
pressure device (E0562) and a continuous positive airway pressure (CPAP) device (E0601). 
 
You asked the Plan to pre-approve a CPAP device and a humidifier. You say that the requested devices are 
medically necessary. The Plan denied your request. The Plan says the requested devices do not meet criteria. 
 
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 CPAP device and a humidifier. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have OSA and was prescribed cpap. The clinical note of 6/2/22 
indicates you are not tolerating the cpap, and the decision was made to refer for an oral appliance. The records 
do not include usage data for an identifiable time frame. It appears you do not intend to continue using the 
device, and it is not known whether the usage to date meets Medicare requirements. 
 
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 CPAP device and a humidifier have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a humidifier, heated, used with a positive airway pressure device 
(E0562) and a continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on 
February 15, 2022, to February 22, 2022. 
 
You asked the Plan to waive the copayment for specialist visits. You say that the enrollee went into 
rehabilitation for a broken pelvis and developed a stage 4 bed sore. You say the bed sore was a result of 
medical negligence and the enrollee should not have to pay for the services. The Plan denied your request. The 
Plan says the cost-sharing has been applied correctly. 
 
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 enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment for physician/practitioner services. In this case, the $40 copayment applies to each 
Medicare-covered specialist visit.  
 
The enrollee has been asked to pay an $80 copayment for two specialist visits provided between February 15, 
2022, and February 22, 2022. Specialist visits fall within the physician/practitioner services, including doctors 
office visits 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 specialist office visits provided on February 
15, 2022, to February 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services rae 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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has Vertebrogenic low back pain. The Intracept procedure remains 
experimental. More research is needed to show safety and efficacy. 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the out-of-network dialysis services. You say that you do not want to 
change providers. The Plan denied your request. The Plan says this provider is no longer in-network. There are 
network providers available. The services are not 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services.  
 
 
 
 Therefore, we decided that the Plan does not have to pre-approve dialysis services 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 dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dialysis services. You say that you do not want to change the enrollee to a 
new dialysis center. The Plan denied your request. The Plan says rules for coverage for OON care have not 
been met. 
 
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 
dialysis services to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 9, 2021, to April 
19, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record at the DRG billed. The Plan denied your request. The Plan says DRG 871 is not appropriate as the diagnosis of sepsis due to enterococcus (A41.81) is not supported in the medical 
record. The Plan argues that DRG 602 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis due to Enterococcus (A41.81) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that the enrollee with a past history of chronic atrial 
fibrillation, sick sinus syndrome, hypertension, hyperlipidemia, coronary artery disease (CAD), and B cell 
lymphoma, presented with right arm pain and swelling. The emergency department exam documented vital 
signs of temp 99.0F, pulse 80, respiratory rate 22, blood pressure 123/75 and pulse oxygen saturation (SpO2) 
97% on room air. The enrollee was described as alert, oriented, lungs clear to auscultation bilaterally, no 
respiratory distress, skin changes consistent with moderate to severe cellulitis and no focal neurologic deficits. 
Laboratory test results included a white blood cell count (WBC) of 11K, platelet count of 384K, blood urea 
nitrogen (BUN) 11, creatinine 0.69, total bilirubin 0.3, and lactic acid 2.3. The enrollees chest x-ray revealed 
pulmonary edema plus minus small pleural effusions. She was diagnosed with right upper extremity cellulitis 
and admitted for further care. Treatment included IV fluid and IV antibiotics. While it is acknowledged that the 
records include a physician-documented diagnosis of sepsis, and that Systemic Inflammatory Response 
Syndrome (SIRS) signs were present along with an elevated lactic acid, the clinical findings in the record do 
not sufficiently support the diagnosis of sepsis based on Sepsis 3 criteria. The review has determined that the 
medical records did not support the billing of sepsis due to enterococcus (A41.81). 
 
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 care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from April 9, 2021, to April 19, 2021, as 
billed with Diagnosis Related Group (DRG) 871.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 8, 2022. 
 
You asked the Plan to pay for the physician's services. You say that do not require authorization because your 
condition is classified as catastrophic. The Plan denied your request. The Plan says in most cases, care you 
receive from an out-of-network provider will not be covered except for emergency care or urgently needed care 
that you get from an out-of-network provider, dialysis services for enrollees who traveled outside the Plans 
service area and are not able to access contracted providers and if you need medical care that Medicare requires 
our Plan to cover and we do not have providers available in our network to provide the service, you can get this 
care from an out-of-network provider. You will need to obtain authorization from the plan prior to seeking 
care. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 8, 2022.
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 no one to assist you at home. The Plan 
denied your request. The Plan says that the services you need can be provided safely in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a leg fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 
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 you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF 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.