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 made significant progress in physical and 
occupational therapy and you can now tolerate IRF level of care. The Plan denied your request. The Plan says 
you can be managed 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. Our 
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation.  Your care needs can be met at a lower level of 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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the charge for ambulance services provided on July 23, 2021 
 
You asked the Plan to reduce the charge for ambulance services. You say that you should be charged $100. The 
Plan denied your request. The Plan says the deductible amount charged is correct. 
 
 
 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 a $100 
copayment for each non-Medicare covered ambulance stabilization when there is no transport. Deductible does 
apply.  
 
You have been asked to pay $200 towards your deductible. At the time the services were rendered you had not 
met your $500 out-of-network deductible, so you must pay the full cost of the service. Ambulance services falls 
within the Ambulance Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the charge for 
ambulance services provided on July 23, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (41899) provided in an outpatient hospital 
setting on September 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that you needed to have these services done in the 
hospital due to your medical condition. The Plan denied your request. The Plan says the services you received 
are routine dental in nature. The Plan says that routine dental services are not covered by the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth.  These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the extractions (41899) provided in an outpatient hospital setting on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on November 30, 2021, by a 
provider who has opted out of Medicare. 
 
You asked the Plan to pay for the dental services. You say that you would like to be reimbursed for the services 
you received. The Plan denied your request. The Plan says no payment can be made to a provider who has 
opted out of Medicare. 
 
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 the dental 
services provided on November 30, 2021, by a provider who has opted out of Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 8, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were quoted $5,919.50 for dental work. You 
say that you wanted a second opinion. You say that you were provided with a much simpler, less costly 
solution. You also say that you feel this should be covered. The Plan denied your request. The Plan says limited 
oral evaluation is covered once per plan year. The Plan also says that the frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and limited oral evaluation is covered 
once per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on December 3, 2021. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the immediate upper denture (D5130) 
provided on June 2, 2021. 
 
You asked the Plan to pay an additional amount for the dental item. You say that the upper denture you 
received is ill-fitting. You say that you were advised you would have to pay out of pocket for a replacement 
denture. You also say that it is unfair for you to pay out of pocket when the dentures you received do not fit 
properly. The Plan denied your request. The Plan says there is a 40% coinsurance for prosthodontics, including 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are listed as covered, there 
is a 40% coinsurance for dentures. Additionally, the Evidence of Coverage says that dentures are covered once 
every 4 years. Therefore, we decided that the Plan does not have to pay an additional amount for the immediate 
upper denture (D5130) provided on June 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that if you don't receive SNF care, you will end up being 
bed bound. The Plan denied your request. The Plan says under Medicare, the request is not medically 
necessary. 
 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for denture relining (code D5750) you received on September 28, 2021. 
 
You asked the Plan to pay for the denture relining. You say that you paid out of pocket for this service and 
would like reimbursement. The Plan denied your request. The Plan says you have exhausted your denture 
relining benefit.  You are only covered for denture relining once every 24 months, and you already received 
covered denture relining on October 26, 2020. 
 
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's Evidence of 
Coverage explicitly states that you are only covered for denture relining once every 24 months.  Since you had 
denture relining on October 26, 2020, you were not eligible for another denture relining on the date of service in question in this appeal. Therefore, we decided that the Plan does not have to pay for denture relining (code 
D5750) you received on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) intraoral periapical firs x-ray 
(D0220) intraoral periapical each additional x-ray (D0230) provided December 6, 2021 from an out of network 
provider. 
 
You asked the Plan to pay for the dental services. You say that you are being asked to pay $191 for the services 
and would like to appeal for the dental x-ray and exam that was denied. The Plan denied your request. The Plan 
says enrollee's must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
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 
limited oral exam (D0140) intraoral periapical firs x-ray (D0220) intraoral periapical each additional x-ray 
(D0230) provided December 6, 2021 from an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chiropractic services provided on 
September 22 to November 17, 2021. 
 
You asked the Plan to waive the coinsurance for chiropractic services. You say that you were assured by 
customer service representatives of the Plan that you would be reimbursed for the services at issue. The Plan 
denied your request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for routine chiropractic services.  
We examined the case record and determined that you have been asked to pay 20% of the Medicare-allowed 
charges for each session for chiropractic services. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
chiropractic services provided on September 22 to November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and drug testing provided on November 18, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and drug testing. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 
 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 the office visit and drug testing provided on 
November 18, 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 problem focused exam (D0140), and occlusal adjustment 
(D9951) provided on December 1, 2021 
 
You asked the Plan to pay for the dental services. You say that you told the provider ahead of time to not do 
anything that was not covered as you would not be able to pay for it. You say that you feel you should have 
been informed before anything was done that it was not covered. You also say that you feel you should not be 
responsible for these charges. The Plan denied your request. The Plan says problem focused exam is not a 
covered service. The Plan says that occlusal adjustment 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 Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the problem focused exam and 
occlusal adjustment are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the problem focused exam (D0140), and occlusal adjustment (D9951) provided on 
December 1, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a permanent below knee prosthesis with advanced foot 
and ankle parts. 
 
You asked the Plan to pre-approve the prosthesis with advanced foot and ankle parts. You say that by denying 
the services recommended for her by her surgeon and prescribing physician this is preventing the enrollee from 
returning to her involvement in her community and personal life. The Plan denied your request. The Plan says the enrollee does not meet the criteria as the enrollee's stump is still not healing well and recently required a 
debridement with VAC placement. 
 
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 prosthesis with advanced foot and 
ankle parts. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found as there is a noted ulcer of the stump; guidelines have not 
been met as the status of the residual limb has noted pathology. There is limited published, large-scale, long-
term peer-reviewed literature that shows this request to be an effective and/or safe treatment with an ulcer on 
the residual stump. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage and the requested permanent below-the-knee prosthesis 
with advanced foot and ankle parts, in this case, is not medically reasonable or 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 prosthesis with advanced foot and ankle parts have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a permanent below knee prosthesis with advanced foot 
and ankle parts.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder arthroplasty services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in severe pain. The Plan 
denied your request. The Plan says the enrollee does not have rheumatoid arthritis, fracture, or subluxation. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for unspecified rotator cuff tear or rupture of the right 
shoulder. He presented with pain in the right shoulder (that is worse with use) to the front and deep inside. 
Exam reveals a prominent acromioclavicular joint with cystic formation over this area and crepitation with 
range of motion. Overhead motion is about 150 degrees. Empty can, Hawkin's are positive. There is very 
limited internal rotation due to stiffness. However, detailed documentation is not evident regarding imaging 
findings corroborating a massive rotator cuff tear. The computed tomography (CT) of the right shoulder has the 
impression of severe right sternoclavicular joint osteoarthritis; mild glenohumeral joint degenerative change; 
coracohumeral interval narrowing which can predispose to subcoracoid impingement; mild acromioclavicular 
joint osteoarthritis. There is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an 
effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested service is not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder arthroplasty services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total ankle replacement. 
 
You asked the Plan to pre-approve total ankle replacement. You say that this surgery is medically necessary 
because the patient tried home exercise in 2021. The Plan denied your request. The Plan says total ankle 
replacement does not meet the Plan's internal coverage criteria. Based on this policy, total ankle replacement is 
contraindicated in peripheral neuropathy or Charcot syndrome of the foot. 
 
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 total ankle replacement. Our reviewer 
says that total ankle replacement is not medically necessary. Our physician reviewer found there is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the overall noted pathology. The Plans internal criteria are in alignment with the current 
published, long-term peer-reviewed literature. Both indicate that the surgical procedure, total ankle 
arthroplasty, has not been proven for the treatment of peripheral neuropathy or Charcot syndrome in the foot. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. Therefore, the requested total ankle replacement, in this case, is not medically reasonable or 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 total ankle replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve total ankle replacement.
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. The Plan denied your request. The Plan says you do not require 
aggressive therapies by an intensive team. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital with gangrene of the left foot requiring below the knee 
amputation. The most recent therapy notes indicate that you require extensive assistance with mobility.  The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation 
therapy 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 inpatient rehabilitation facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.