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

 
We decided that the Plan does not have to pay more for the extractions, of an erupted tooth requiring removal 
of bone and/or sectioning of tooth (D7210 x 11), removal of residual tooth roots (D7250 x 2), and the 
consultation-diagnostic service (D9310) provided on February 3, 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. Additionally, you have exhausted the annual maximum dental benefit for this calendar year.  
 
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. 
Additionally, the Plan has issued payment at the maximum allowable dental benefit of $2,000 for the 2023 
calendar year. Therefore, we decided that the Plan does not have to pay more for the extractions, of an erupted 
tooth requiring removal of bone and/or sectioning of tooth (D7210 x 11), removal of residual tooth roots 
(D7250 x 2), and the consultation-diagnostic service (D9310) provided on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on February 8, 2023. 
 
You asked the Plan to pay 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 this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on August 23, 2022. 
 
You asked the Plan to pay for the dental service. 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 service 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 service provided was exhausted on date of service February 16, 2022. Specifically, 
the Plans contract states that one dental cleaning is covered per year.  
  
 
 
You previously received a dental cleaning on February 16, 2022, less than one year prior, which was paid for 
by the Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that 
the Plan does not have to pay for the dental cleaning (D1110) provided on August 23, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
4, 2022, through December 15, 2022. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary for the enrollee's 
medical needs. The Plan denied your request. The Plan says the enrollee did not have skilled nursing needs.  
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from December 4, 2022, through December 15, 2022.
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 in consideration of the enrollee's prior medical 
history, active comorbidities, and risk for medial instability while increasing activity, the IRF setting is the 
most appropriate to reach the desired outcomes. The Plan denied your request. The Plan says the enrollee does 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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. There is not a reasonable expectation that 
the enrollee 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction and bone replacement graft (D7140, D7953) 
provided on January 5, 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 bone replacement graft denied correctly as 
they do not fall within your dental benefits. The cost-sharing applied correctly based on the extraction 
provided. 
 
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, bone replacement grafts are not among 
those covered under this benefit. 
 
You have been asked to pay a $35 copayment for an extraction. This item/service falls within the Dental 
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 pay for an extraction and bone replacement graft 
(D7140, D7953) provided on January 5, 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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says while the member would continue to benefit from physical and occupational 
therapy, the documentation reviewed does not support that the member's functional status requires 3 hours of 
therapy per day. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 the member is clinically complex with 
multiple acute and chronic conditions requiring extended medical and rehabilitative care. The Plan denied your 
request. The Plan says the request is not medically necessary because the enrollee is receiving the care they 
need in the hospital where they are now and there is no need to transfer to the LTACH currently. They can stay 
in the hospital until they are safe for transfer or discharge. 
 
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 transfer to the LTACH is not medically necessary as the patient is not yet stable for transfer and as it would not be clinically advantageous. Completion of treatment at the current facility is 
recommended. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110), and periodic oral evaluation - 
established patient (D0120) provided on November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was your first oral exam and cleaning under 
your plan. The Plan denied your request. The Plan says your benefit for the requested services $3,000 dollar 
limit was met. We've paid the annual limit allowed by your dental plan for this benefit year. 
 
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 October 13, 2022. 
Therefore, we decided that the Plan does not have to pay for prophylaxis - adult (D1110), and periodic oral 
evaluation - established patient (D0120) provided on November 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Porto mobility 2023 Ranger Discovery lightweight 
foldable weatherproof exclusive electric wheelchair (K0899). 
 
You asked the Plan to pre-approve the electric wheelchair. You say that you are asking for a wheelchair that 
will make it easy for you to move in, and easy for you to carry. The Plan denied your request. The Plan says the 
requested wheelchair is not covered. The Plan also says there was no medical information provided as to why 
you cannot use a brand covered by the Plan.  
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage organizations may limit 
coverage to certain Durable Medical Equipment (DME) brands, items, and supplies.  
  
We looked at the file and Medicare rules. The Plan requires the use of DME, including wheelchairs, that are 
brands that are covered by the Plan. The wheelchair brand you have requested is not on the Plan's approved 
DME brand list. Therefore, we decided that the Plan does not have to pre-approve a Porto mobility 2023 
Ranger Discovery lightweight foldable weatherproof exclusive electric wheelchair (K0899).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99072 and 94761 billed for date of service 
September 20, 2022. 
 
You asked the Plan to pay for procedure code 99072. You say that medical records were provided. The Plan 
denied your request. The Plan says The codes are 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. We find that procedure code 94761 has a status indicator of T. 
In this case, this code is not separately payable as it was billed with other payable services. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 99072 and 94761 billed for date of service September 20, 2022.
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 for the enrollee 
to make measurable gains and improve medical status. The Plan denied your request. The Plan says the 
services that the enrollee needs can be provided safely in another setting such as a skilled nursing facility or 
home with home health services.  
 
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 enrollee does 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: 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 the submitted medical records support the need for 
IRF admission.  The Plan denied your request. The Plan says the enrollee does 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 enrollee is medically stable with no acuity or complexity despite multiple 
comorbidities and does not need a physical medicine and rehabilitation physician's supervision 3 times a week 
in an IRF. No acute rehabilitation skilled nursing needs are identified or documented. The enrollee does not 
need specialized intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week 
with multidisciplinary approach in an IRF. The document does not support necessity for admission to an IRF 
due to lack of acute medical illness/complexity or nursing needs. The enrollee's rehabilitation needs can be 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the hospital clinic visit provided on 
February 22, 2023. 
 
You asked the Plan to waive the cost share for the clinic visit. You say that you should not have to pay for a 
room at the doctor office. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to outpatient surgery, including 
services provided at hospital facilities. Your contract with the Plan also clearly says that you must pay 4% 
coinsurance for each outpatient hospital visit. 
 
 
 You have been asked to pay $98.30, which satisfies the deductible for the clinic visit. The remaining allowed 
amount is $12.39 ($110.69 allowed amount - $98.30 deductible = $12.39. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $500 deductible which applies to outpatient surgery, 
including services provided at hospital facilities. This cost sharing is a contractual obligation that had not been 
met at the time the clinic visit was received on February 22, 2023. 
 
You have also been asked to pay $0.50, which is 4% coinsurance of the remaining allowed amount for the 
clinic visit ($12.39 remaining allowed amount x 4% = $0.50). This item/service falls within the outpatient 
surgery, including services provided at hospital facilities. 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 cost share 
for the hospital clinic visit provided on February 22, 2023.
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 admission to a SNF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for SNF 
care. 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: 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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says  the request is not medically necessary, the services the enrollee needs can 
be provided safely in other settings, for example, a skilled nursing facility, home with home health services or 
home with outpatient therapy. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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.