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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
28, 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 a comprehensive oral evaluation (D0150) provided on March 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral water jet ablation of the prostate (0421T). 
 
You asked the Plan to pre-approve transurethral water jet ablation of the prostate. You say that this is medically 
necessary. The Plan denied your request. The Plan says the indications for coverage are not met. 
 The Plan follows Medicare rules. Medicare rules say that transurethral water jet ablation of the prostate can be 
covered when specific criteria are 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 transurethral water jet ablation of the 
prostate. Our reviewer says that the enrollee does not meet coverage criteria. Our physician reviewer found the 
indication for coverage is not met because the enrollee has an International Prostate Symptom Score (IPSS) 
score of 0, and there is no documentation provided of the following: a prostate volume of 30-150 cc by 
transrectal ultrasound (TRUS) and a maximum urinary flow rate (Qmax) less than or equal to15 milliliters with 
a voided volume greater than 125 cc and there is no documentation of failure or intolerance after at least 3 
months of conventional medical therapy for LUTS/BPH. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral water jet ablation of the prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral water jet ablation of the prostate (0421T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a semi-precision abutment placement (D6191) provided on 
February 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 semi-
precision abutment placement (D6191) provided on February 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography, heart, without contrast material, 
with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve computed tomography, heart, without contrast material, with quantitative 
evaluation of coronary calcium. You say that this is medically necessary. The Plan denied your request. The 
Plan says Medicare does not cover the requested service for screening purposes. 
 
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 computed tomography, heart, without 
contrast material, with quantitative evaluation of coronary calcium. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is insufficient support in the peer-reviewed literature demonstrating a significant benefit of 
computed tomography (CT) imaging of the heart with quantitative evaluation of coronary calcium in guiding 
optimal management of this patient. As such, CT imaging of the heart without contrast material with 
quantitative evaluation of coronary calcium is considered experimental/investigational for the evaluation and 
management of this patient's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computed tomography, heart, without contrast material, with quantitative 
evaluation of coronary calcium have not been met. Therefore, we decided that the Plan does not have to pre-
approve computed tomography, heart, without contrast material, with quantitative evaluation of coronary 
calcium (75571).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient eye examination (92004) provided on April 04, 
2023. 
 
You asked the Plan to pay for a new patient eye examination (92004). You say that an authorization should be 
on file for the members stay at this facility. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a new patient eye 
examination (92004) provided on April 04, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the vitamin injections billed with procedure codes J3490, 
J3411, J3415, J3420 on February 20, 2023. 
 
You asked the Plan to pay for the vitamin injections. You say that the claim should be reprocessed The Plan 
denied your request. The Plan says the vitamin injections are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
  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 the vitamin injections. Our reviewer says 
that the vitamin injections are not medically necessary. Our physician reviewer found that the documentation 
did not sufficiently support the use of these treatments as there were no measured low vitamin levels or 
description of their inability to get their vitamins via food or supplementation. The enrollee also does not have 
an FDA approved indication for these treatments and the major drug compendia and current literature do not 
support their use for the enrollee's condition. 
 
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 vitamin injections have not been met. Therefore, we decided that the Plan 
does not have to pay for  the vitamin injections billed with procedure codes J3490, J3411, J3415, J3420 on 
February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing and interim partial 
denture (D4342, D5820) provided on April 4, 2023, to April 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 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 
periodontal scaling and root planing and interim partial denture (D4342, D5820) provided on April 4, 2023, to 
April 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71101 billed for date of service January 26, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the service performed was appropriate with the 
diagnosis code. The Plan denied your request. The Plan says the diagnosis is not appropriate with the modifier 
appended. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 71101 was billed with diagnosis code S20.219A, contusion of unspecified front wall of 
the thorax. The medical records show the enrollee received a chest x-ray for the left side. There is a more 
appropriate diagnosis code to describe the laterality of the service. 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 procedure code 71101 billed for date of service January 26, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from September 20, 
2022, to November 30, 2022. 
 
You asked the Plan to pay for the SNF services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the SNF services by a contract provider. Coding issues between Par providers and 
the health Plan should be resolved internally and do not affect coverage for the enrollee. The file does not show 
that the plan provided notice that the SNF services would not be covered. Under Medicare rules, this means the 
SNF services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
skilled nursing facility (SNF) services provided from September 20, 2022, to November 30, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are necessary for you to recover from 
the trauma you suffered. You also say you will not be able to care for yourself if you are discharged to home.  
The Plan denied your request. The Plan says you do not meet Medicare guidelines for services in an IRF.  
 
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 have complex or intensive rehabilitation needs. Our physician 
reviewer found that hip fracture rehabilitation is routinely done at levels of care other than an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
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 the enrollee has lumbar stenosis. The cause of degenerative back 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).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has medical needs that 
cannot be managed at lower levels, and they could also benefit from continued physical therapy (PT) to 
increase balance, gait and endurance. The Plan denied your request. The Plan says the enrollee's records do not 
show that they need continued treatments and care that can only be given in a hospital setting.  
 
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 improving with current treatment 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 soon. The enrollee does not require services at the LTACH that 
are not already available at the current 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 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: 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 the services are medically necessary to help you 
become independent again and you are now able to participate in therapy. The Plan denied your request. The 
Plan says you do not meet the criteria for admission to an IRF.  
 
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 require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services (97110, 97112, 97140), 
provided on January 3, 2022. 
 
You asked the Plan to pay for the PT services. You say that the services should be covered. The Plan denied 
your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the PT services was not filed until February 2, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the physical therapy (PT) services (97110, 97112, 97140), provided on 
January 3, 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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's medical needs 
are being met in the current setting.  
 
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 in their current acute care setting provided 
by the Health Plan. Documentation does not support that LTACH services are medically appropriate at this 
time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service August 10, 
2021, to September 8, 2021. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the required documentation was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the medical records provided do not include an OASIS assessment. Without these records, we are 
unable to determine if the documentation supports the billing. 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 care billed for dates of service August 10, 2021, to September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you prefer to admit to acute rehab because I was 
independent and active before coming to the hospital and will to return to being independent as quickly as 
possible. You also say that your goal is to return home within the next 7 to 10 days, and you are fearful that 
will not happen if you go to a nursing home. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for admission to an IRF. 
 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 your nursing, medical and rehabilitation needs does not require an 
acute 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, and an intensive 
rehabilitation therapy program. Our reviewer found that while the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.