Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of pain is not clear. 
 
   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records support the need for 
LTACH admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
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 enrollee appears to be stable and should only require short-term additional acute 
care services that can safely be provided at the current facility until more stable and appropriate for transfer to a 
lower level of care.  The enrollee does not require services at the LTACH that are not already available at the current facility. 
Transfer to the LTACH is not medically necessary as it would not be clinically advantageous. 
 
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 the LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service August 31, 
2022.  
 You asked the Plan to pay for procedure code A0425. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value can be paid with an appropriate modifier, on separate lines, when the MAI value is 1. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 916 units of 
this code on one line, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A0425 billed for date of service August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), panoramic 
radiographic image (D0330), dental cleaning (D1110), and the topical application of fluoride varnish (D1206) 
provided on April 14, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
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. 
 
  
 
 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the periodic oral evaluation (D0120), 
panoramic radiographic image (D0330), dental cleaning (D1110), and the topical application of fluoride 
varnish (D1206) provided on April 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on April 5, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that no provider or supplier shall receive 
payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the 
Medicare program 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing services (D4341 D4342) 
provided on December 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 29, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing services 
(D4341 D4342) provided on December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing-four or more teeth 
per quadrant (D4341 x 4) provided on February 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the dental services 
provided has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the services provided was exhausted on July 13, 2021.   
 
 
 
 
Specifically, the Plans contract states that periodontal scaling and root planing is covered once every three 
years per quadrant. You previously received these dental services on May 26, 2021 and July 13, 2021 
accordingly, less than three years prior, which were paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for the services provided in this case. Therefore, we decided that the Plan does not have to 
pay for the periodontal scaling and root planing-four or more teeth per quadrant (D4341 x 4) provided on 
February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the complete denture - maxillary. You say that the actual denture does not 
fit. The Plan denied your request. The Plan says your benefit for the complete denture - maxillary has already 
been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the complete denture - maxillary was exhausted on date of service November 15, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary, and when at least one indication listed in the LCD is met.  
 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee is on statins and is 
asymptomatic. The LCD criteria indicate coverage for CT calcium scoring is possible if there is a calculated 
lifetime risk of coronary artery disease of 10-20%. No such calculation is in the records.  
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on February 06, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you do not agree 
with having a copayment for PT that is part of your surgery. The Plan denied your request. The Plan says this 
cost sharing was charged 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). Your contract with the Plan clearly says that you must pay a $10 
copayment for outpatient rehabilitation services.  
You have been asked to pay a $10 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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 waive the copayment 
for each physical therapy (PT) visit provided on February 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist office visit provided on 
April 21, 2023. 
 
You asked the Plan to waive the copayment for each specialist office visit. You say that you do not feel you are 
liable for the specialist office visit. The Plan denied your request. The Plan says this cost sharing was charged 
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). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services.  
You have been asked to pay a $35 copayment for each specialist office visit. This item/service falls within the 
physician/practitioner 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 waive the copayment for 
each specialist office visit provided on April 21, 2023.
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 care. You say that you will not be able to receive proper care if you are 
discharged. The Plan denied your request. The Plan says your SNF benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from April 1, 2023, to July 9, 
2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, and teledentistry 
services (D9995, D0140, D0210) provided on  March 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. This benefit does not include limited oral evaluations. Additionally, the teledentistry 
services are covered as part of another 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, certain limitations apply. This benefit 
does not include limited oral evaluations. Additionally, the teledentistry services are covered as part of another 
service. The record shows your benefit for the requested item or service was exhausted on date of service July 
29, 2021 (D0210). Therefore, we decided that the Plan does not have to pay for a limited oral evaluation, 
intraoral x-ray, and teledentistry services (D9995, D0140, D0210) provided on  March 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and extraction (D0220, D7210) provided 
on April 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your plan benefits. 
 
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 an intraoral x-ray and extraction 
(D0220, D7210) provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral  comprehensive series of radiographic images 
(D0210) provided on March 23, 2023. 
 
You asked the Plan to pay for the intraoral  comprehensive series of radiographic images. You say that you 
are not responsible for any charges from the dental claim. The Plan denied your request. The Plan says your 
benefit for the intraoral  comprehensive series of radiographic images has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the intraoral  comprehensive series of radiographic images was exhausted on date of 
service September 23, 2021. Therefore, we decided that the Plan does not have to pay for an intraoral  
comprehensive series of radiographic images (D0210) provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a placement of intra-socket biological dressing and local 
anesthesia services (D9215, D7922 x2) provided on April 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
placement of intra-socket biological dressing and local anesthesia services (D9215, D7922 x2) provided on 
April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays, intraoral x-rays, cleaning, and a 
comprehensive oral evaluation (D0274, D0230, D0150, D1110) provided on February 6, 2023, to March 20, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for bitewing x-rays, intraoral x-rays, cleaning, and a comprehensive oral evaluation (D0274, D0230, 
D0150, D1110) provided on February 6, 2023, to March 20, 2023.
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 you are asking for approval per the doctors request 
for acute inpatient rehabilitation admission. The Plan denied your request. The Plan says based on Medicare 
guidelines, the IRF services you are requesting 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 the documentation does not support necessity for admission to an IRF. The 
complexity of your medical, and therapy needs (combined complexity) does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs 
can be safely provided in an alternate and low intensity setting such as in a skilled nursing 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist office visit provided on 
April 19, 2023. 
 
You asked the Plan to waive the copayment for each specialist office visit. You say that you do not feel you are 
liable for the specialist office visit. The Plan denied your request. The Plan says this cost sharing was charged 
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). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services. 
 
You have been asked to pay a $35 copayment for each specialist office visit. This item/service falls within the 
physician/practitioner 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 waive the copayment for 
each specialist office visit provided on April 19, 2023.