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

 
We decided that the Plan has to pre-approve a pontic (D6245) for tooth #4 and retainer crowns (D6740) for 
tooth #3 and #5. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has no other missing teeth in 
the arch and a partial would not provide the same chewing function. The Plan denied your request. The Plan 
says that there was no documentation showing that the enrollee is precluded from the use of a removable 
prosthesis. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the criteria for coverage for a fixed bridge replacing missing tooth #4 is necessary. Our physician reviewer 
found the documentation indicates that tooth #4 was recently lost. There are no other missing teeth and the 
enrollee's bone support is good. It is medically reasonable to place a fixed bridge to provide good bilateral 
mastication and to prevent the drifting of the adjacent teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a pontic (D6245) for tooth #4 and retainer crowns (D6740) for tooth #3 and #5.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you have chronic back pain and need 9 
additional physical therapy visits. The Plan denied your request. The Plan says 9 additional physical therapy 
visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that there is no documentation showing that you are 
improving with physical therapy sessions and are needing the unique skills of a professional therapist to 
provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 9 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you cannot afford to pay for these out of 
pocket. The Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 8, 2022.
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 need intense rehabilitation to help you return to 
your previous status. The Plan denied your request. The Plan says an IRF admission is not medically necessary, 
and you can receive the care you need in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an LTACH care. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the tests should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography with interpretation and report 
(92250) provided on January 9, 2023. 
 
You asked the Plan to pay for the fundus photography. You say that you feel this service should be covered. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that intraocular photography is covered when used 
for the diagnosis of such conditions as macular degeneration, retinal neoplasms, choroid disturbances and 
diabetic retinopathy, or to identify glaucoma, multiple sclerosis and other central nervous system abnormalities. 
 
We looked at the file and Medicare rules. Specifically, the records show that your diagnosis is H52.00, defined 
as Hypermetropia, unspecified eye. This diagnosis is not one of the covered conditions for this service. Based 
on this information, we decided that Medicare rules for coverage of the fundus photography have not been met. 
Therefore, we decided that the Plan does not have to pay for the fundus photography with interpretation and 
report (92250) provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you wanted the enrollee to see this dentist 
because he has seen him in the past and is the closest. The Plan denied your request. The Plan says dental 
services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve dental 
services provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #3 and crowns (D6752) tooth 
#2 and #4. 
 
You asked the Plan to pre-approve the dental services. You say that the bridge is medically necessary for the 
enrollee. The Plan denied your request. The Plan says documentation does not support that the enrollee cannot 
use a removable prosthesis. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the service does not meet the criteria for coverage. Our physician reviewer found due to the inadequate 
radiographs submitted, a determination of medical need for this service could not be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic (D6245) for tooth #3 and crowns (D6752) tooth #2 and #4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), a partial 
mandibular denture (D5214), and core build up (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat and need new dentures as 
soon as possible. The Plan denied your request. The Plan says your benefit for the requested dentures has 
already been exhausted. The Plan also says that core build up (D2950) is not covered by 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, certain limitations apply. The record 
shows your benefit for a complete set of dentures was exhausted on date of service December 3, 2020. Core 
build up is not among the services covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve a complete maxillary denture (D5110), a partial mandibular denture (D5214), and core 
build up (D2950).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service August 1, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 99291. 
 
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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 93042 billed for date of service August 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services billed for dates of service July 3, 
2022, to August 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim is showing the correct revenue code. 
The Plan denied your request. The Plan says the rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that the home health services were not billed with a G code as 
required. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services billed for dates 
of service July 3, 2022, to August 1, 2022.
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 requesting reconsideration for the denial 
of an IRF admission. The Plan denied your request. The Plan says the request for admission to an IRF is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration for the denial of an LTACH admission. You say the enrollee's condition has stabilized, and 
they are ready for discharge from the acute care hospital. The Plan denied your request. The Plan says medical 
necessity criteria for admission to the LTACH has not been met. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the tests should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on October 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you want SNF services, and you are not ready to go 
home. The Plan denied your request. The Plan says 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have 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 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a posterior spinal spacer. 
 
You asked the Plan to pre-approve the insertion of a posterior spinal spacer. You say that this device is 
medically necessary for the treatment of the patient's lumbar spinal stenosis. The Plan denied your request. The 
Plan says the insertion of a posterior spinal spacer is not medically necessary. There are currently no clinical 
indications for this technology. 
 
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 insertion of a posterior spinal 
spacer. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found interspinous process spacers are experimental at this time. 
More research is needed before they can be considered medically reasonable and 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 insertion of a posterior spinal spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of a posterior spinal spacer.