Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion consultation and possible treatment to 
be provided out-of-area (OOA) by an out-of-network (OON) urology/oncology provider. 
 
You asked the Plan to pre-approve the OOA/OON urology/oncology services. You say that you feel that you 
have the right to get care from the provider you wish. You believe that this should be approved by the Plan. 
The Plan denied your request. The Plan says your Plan only covers non-emergency OON care when the 
services cannot be provided by network providers. In this case, there are several qualified providers in the 
network who can provide the second opinion you desire and provide treatment. There is no service available 
from the OON provider in Texas that is not available within the network. 
 
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 
a second opinion consultation and possible treatment to be provided out-of-area (OOA) by an out-of-network 
(OON) urology/oncology provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral 
- periapical first radiographic image (D0220), and endodontic therapy, molar tooth (excluding final restoration) 
(D3330) provided October 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the limited oral exam, intraoral x-ray and root canal. You say that you dentist set 
up the appointment for your necessary services. The Plan denied your request. The Plan says these services are 
not covered because they were provided OON. 
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 the limited 
oral exam, intraoral x-ray and root canal when the services are rendered by a participating provider. 
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the limited oral exam, intraoral x-ray and root canal have not been met. Therefore, we decided that the Plan 
does not have to pay for limited oral evaluation - problem focused (D0140), intraoral - periapical first 
radiographic image (D0220), and endodontic therapy, molar tooth (excluding final restoration) (D3330) 
provided October 19, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and intraoral-
complete series (D0210), provided on December 1, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says you have exceeded the maximum frequency limitations for this service. 
 
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 comprehensive oral evaluation (D0150), and 
intraoral-complete series (D0210), provided on December 1, 2021.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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 enrollee is medically stable, with no new medical issues, does not need physical medicine and rehabilitation 
physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. The enrollee does not need intensive therapies, consisting of 
at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in 
an IRF. At the current functional level with debility, he will not tolerate the therapies, and is not likely to make 
a significant functional recovery in an IRF. While he may benefit from physical and occupational therapy, the 
enrollee's rehab can be safely provided at a lower intensity and alternate setting. Our physician reviewer found 
that the enrollee's 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that relevant medical have been included and will 
provide sufficient support for reconsideration. The Plan denied your request. The Plan says the member does 
not have complex nursing or medical needs requiring a resource intensive inpatient hospital 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 that there are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical and/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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on June 23, 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 22845 is not supported. 
 
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, the CPT Code Manual definition of code 22845 is anterior instrumentation; 2 to 3 vertebral 
segments (List separately in addition to code for primary procedure). 
 
We find that CPT code 22845 is not supported in the medical record. Specifically, there is no documentation of 
anterior instrumentation of 2 to 3 vertebral segments. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the surgical services rendered on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy (D3346) for 
tooth #8. 
 
You asked the Plan to pre-approve retreatment of a previous root canal. You say that this service is necessary. 
The Plan denied your request. The Plan says this service is not covered by your dental benefit. 
 
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 
retreatment of previous root canal therapy (D3346) for tooth #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve a complete upper and lower denture. You say that your current dentures do 
not fit properly, and you need new ones. The Plan denied your request. The Plan says you will exceed the 
frequency limit for dentures. 
 
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 a complete 
upper and lower denture once every five plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper and 
lower denture were previously covered on November 13, 2019. Based on this information, we decided that the 
Plan's frequency limit for coverage of a complete upper and lower denture will be exceeded. Therefore, we 
decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete denture 
- mandibular (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge comprised of a false tooth (D6240) and 
retainer crowns (D6750) for teeth #4-#6. 
 
You asked the Plan to pre-approve the dental bridge. You say that this dental bridge is necessary. The Plan 
denied your request. The Plan says the criteria for coverage of a dental bridge are not met in this case. 
 
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 dental bridges 
when they are provided to replace one missing front tooth on the upper jaw or two missing adjacent front teeth 
on the lower jaw.  We looked at the file and the Plan's rules. The bridge in this case is requested to replace tooth #5, which is 
defined as a posterior (back) tooth. The Plans benefit for bridges does not offer coverage for bridges intended 
to replace posterior teeth. Based on this information, we decided that the Plan's rules for coverage of the dental 
bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental bridge 
comprised of a false tooth (D6240) and retainer crowns (D6750) for teeth #4-#6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and to pay an additional 
amount for the extraction (D7210) provided on October 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that the oral surgeon had difficulty removing your 
tooth. You say that you cannot afford this bill. You also say that you should be reimbursed. The Plan denied 
your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the frequency 
limit has been exceeded. The Plan also says that out of network providers may bill you for any amount greater 
than what the plan pays the provider. 
 
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 and the services are listed as covered, 
the frequency limit of 1 limited oral evaluation has been exceeded. The record shows that the Plan paid for a 
limited oral evaluation that you received on September 23, 2021. Additionally, out of network providers may 
bill you for any amount greater than what the plan pays the provider. Therefore, we decided that the Plan does 
not have to pay for the limited oral evaluation (D0140) and to pay an additional amount for the extraction 
(D7210) provided on October 20, 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 enrollee can be transferred to an 
LTACH level of care for continuation of care for complex medical needs that require ongoing acute care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer to an LTACH. 
 
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 patient does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Our physician reviewer also found that an 
admission to an LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a 
lower level of care may be considered when treatment has completed.  
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard for teeth grinding (D9944). 
 
You asked the Plan to pre-approve the dental guard. You say that the dental guard is necessary to guarantee the 
protection of future dental work. The Plan denied your request. The Plan says this service is not covered by 
your dental benefit. 
 
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 an 
occlusal guard for teeth grinding (D9944).
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 need intense rehabilitation so you can return to 
your maximum function. The Plan denied your request. The Plan says the requested IRF services 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. 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. 
 
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: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from June 13, 2021, to June 24, 
2021. 
 
You asked the Plan to pay for the home health services. You say that the documentation required was all 
submitted to the Plan in a timely manner. The Plan denied your request. The Plan says that the Request for 
Anticipated Payment (RAP) was not received until more than 5 days from the start of this episode of care. 
 
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 has failed to provide sufficient evidence to support its denial rationale 
regarding the dates on which the RAP and/or the final claim were submitted. The Plan states that the RAP was 
not received until July 21, 2021; however, the file does not provide a copy of the RAP supporting the date on 
which it was received. As such, reduction of the payment amount on the final claim (for which there is also no 
evidence to support when it was received), is not appropriate. We find that the Plan's denial of payment for this 
final claim is not substantiated. Therefore, we decided that the Plan has to pay for the home health services 
provided from June 13, 2021, to June 24, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880). 
 
You asked the Plan to pre-approve the duplex scan. You say that this service is medically necessary, and you 
are not aware of what tests/procedures the provider is performing and trust their judgement. The Plan denied 
your request. The Plan says the criteria for coverage of this ultrasound are not met, and this service therefore is 
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 the duplex scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found as you only had rare dizziness episodes and the physical examination was not able to show 
current and active signs of severe carotid artery disease, this request for a duplex scan of the extracranial 
arteries is not sufficiently supported and will be considered not medically necessary at this time.  
 
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 duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a duplex scan of extracranial arteries (93880).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service August 23, 
2021. 
 
You asked the Plan to pay for procedure code G0453. You say that you have provided medical records to 
support payment of this code. The Plan denied your request. The Plan says the other codes in dispute have been paid.  For code G0453, this code is bundled into payment for code 95940, and you did not bill with a modifier 
that would allow for separate payment. 
 
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 G0453 
is a column II code to column I code 95940. 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 G0453 billed for date of service August 23, 
2021.