Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 22, 2022, through 
June 27, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the review indicates that the enrollee presented to the emergency department (ED) on June 22, 2022 
with abdominal pain. The evaluation revealed gall bladder thickening. He was admitted with a diagnosis of 
cholecystitis and underwent further evaluation. He had an abdominal ultrasound which demonstrated a 
common bile duct stone. He was evaluated by Gastroenterology and General Surgery. He received intravenous 
antibiotics and underwent a laparoscopic cholecystectomy with intraoperative cholangiogram. Post-operatively 
he received intravenous antibiotics and underwent an Endoscopic Retrograde Cholangiopancreatography 
(ERCP) with stone removal. He tolerated the procedure and his diet was advanced. He remained stable and was 
discharged home on June 27, 2022. The review has determined that the record showed that at the time of the 
inpatient admission the admitting physician reasonably expected that the enrollees necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from June 22, 2022, through June 27, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review.  
 
  
The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we 
decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, of a premolar tooth (excluding final 
restoration) (D3320) and periodontal scaling and root planing-four or more teeth per quadrant (D4341 x 4). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under your 
supplemental dental policy. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic 
therapy, of a premolar tooth (excluding final restoration) (D3320) and periodontal scaling and root planing-four 
or more teeth per quadrant (D4341 x 4).
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 physical and occupational therapy 
to maximize your potential for recovery. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and you can receive the care you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the denosumab injection provided on 
November 02, 2022. 
 
You asked the Plan to reduce the coinsurance for the denosumab injection. You say that you were not charged 
this much last time you received the injection. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the denosumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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. The total you owe is $270.12 ($1,350.60 allowed amount x 20% = $270.12). 
Therefore, we decided that the Plan does not have to reduce the coinsurance for the denosumab injection 
provided on November 02, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 14, 2022. 
 
You asked the Plan to pay for imaging services. You say that this should be covered. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for imaging services provided on August 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) and 
surgical access to an implant body (D6011). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 April 4, 2023. Therefore, 
we decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) and 
surgical access to an implant body (D6011).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventative procedure (D1999), and 
drugs/medicaments dispensed at home (D9630), provided on December 28, 2021. 
 
You asked the Plan to pay for D1999 and D9630. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered dental services are not covered 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 an 
unspecified preventative procedure (D1999), and drugs/medicaments dispensed at home (D9630), provided on 
December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on August 18, 2022, by an out-of-
network (OON) provider. 
 
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 the services were rendered by a non-network provider without prior authorization. 
 
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 referring provider 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 drug testing provided on August 18, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve inpatient mental health services to be provided by an OON provider. You 
say that there is no daily therapy or one on one therapy offered in an in-network residential inpatient setting.  
You day that you have been treated for over 20 years with no relief and you would like to go outside of the 
state for treatment. The Plan denied your request. The Plan says the requested services are offered through the Plan with in-network providers. The Plan confirmed with the requested OON provider that they are not 
enrolled with the Medicare program. 
 
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 rules also say 
that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 
 
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. Additionally, the requested OON provider is not enrolled in the 
Medicare program. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health 
services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria for a replacement CGM was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that the RUL of DME cannot be less than 5 years. 
 
  We looked at the file and Medicare rules. Based on the enrollee received their CGM in December of 2019; 
therefore, the RUL for the CGM would be in December of 2024. With this information, we decided that 
Medicare rules for a replacement of the CGM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service August 3, 
2022. 
 
You asked the Plan to pay for procedure code 20936. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 20936 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the gym membership (S9970) 
purchased on January 1, 2022. 
 
You asked the Plan to issue additional reimbursement for this service. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that you are not 
eligible for additional reimbursement of this service. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
  
 
 
The Plans rules for coverage of gym benefits have not been met because you are not eligible for additional 
reimbursement of this service. Specifically, you submitted a receipt for payment of a gym membership in the 
amount of $199.00 for the 2022 calendar year. The Plan previously issued payment to you for this service on 
January 7, 2022 and January 27, 2023 in the amount of $199.01 ($165.84 + $33.17). Therefore, you are not 
eligible for additional reimbursement for this membership. Additionally, as the Plan provides reimbursement 
for up to $250 per calendar year for services covered under the wellness allowance benefit, you may submit 
proof of payment to the Plan for reimbursement of other covered services provided to you under this benefit 
during the 2022 calendar year. Therefore, we decided that the Plan does not have to issue additional 
reimbursement for the gym membership (S9970) purchased on January 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you need this CGM. The Plan denied your request. 
The Plan says the enrollee is not on insulin. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous 
glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing billed with codes 87481, 87491, 87496, 
87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, and 87798 for date of service 
September 30, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 
87653, 87661, and 87798 is not supported in the medical record. Specifically, the panel of tests should be billed 
under a single CPT code to prevent stacking codes. The documentation does not support that the services 
rendered were billed with one code. Based on this information, we decided that Medicare rules for coverage of 
the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory testing billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 
87651, 87653, 87661, and 87798 for date of service September 30, 2022.
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 member's respiratory status was 
previously unstable but has now improved. The Plan denied your request. The Plan says the member does not 
meet the criteria for an LTACH admission. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The requested service cannot be recommended as 
the elements of the coverage rules are not satisfied. 
 
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: 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 you require the care and rehabilitation provided at a 
SNF. The Plan denied your request. The Plan says the member's current functional and medical condition does 
not support the need for a SNF admission. 
 
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 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 identifiable skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. However, you do 
not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. Required services can 
be provided in the home, in an assisted living facility with home health care, or in a long-term care facility on a 
part time basis. 
 
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 more for resin-based composite - two surfaces, posterior 
(D2392) provided on January 25, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you would not have seen the provider if 
you were aware they were out-of-network. 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 resin-based composite - two surfaces, 
posterior (D2392) provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration with 
periradicular surgery (D3431). 
 
You asked the Plan to pre-approve biologic materials to aid in tissue regeneration. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
biologic materials to aid in tissue regeneration with periradicular surgery (D3431).