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

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic (D6740) for teeth 
numbers 22, 23, 26, 27, 28 and a pontic - porcelain/ceramic (D6245) on tooth #24, #25. 
 
You asked the Plan to pre-approve a retainer crown - porcelain/ceramic (D6740) for teeth numbers 22, 23, 26, 
27, 28 and a pontic - porcelain/ceramic (D6245) on tooth #24, #25. You say that the oral reconstruction and 
bite restoration work would be carried out in two stages. You also state that the denial of the second stage 
constitutes an arbitrary abrogation of the service contract previously requested, agreed upon and approved by 
the Plan service manager in the detriment of your oral and general health at present and in the future.  The Plan 
denied your request. The Plan says after evaluating the provided clinical and/or x rays information, there are 
not favorable conditions in the tooth to execute the requested procedure.  
 
  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 a retainer 
crown - porcelain/ceramic (D6740) for teeth numbers 22, 23, 26, 27, 28 and a pontic - porcelain/ceramic 
(D6245) on tooth #24, #25 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 a retainer crown - porcelain/ceramic 
(D6740) for teeth numbers 22, 23, 26, 27, 28 and a pontic - porcelain/ceramic (D6245) on tooth #24, #25. Our 
reviewer says that there would be no medical necessity for the requested services. Our physician reviewer 
found the requested procedures are contra-indicated due to the existing periodontal disease, and due to the 
amount of bone loss present. 
 
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 a retainer crown - porcelain/ceramic (D6740) for teeth numbers 22, 23, 26, 27, 
28 and a pontic - porcelain/ceramic (D6245) on tooth #24, #25 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a retainer crown - porcelain/ceramic (D6740) for teeth numbers 22, 23, 
26, 27, 28 and a pontic - porcelain/ceramic (D6245) on tooth #24, #25.
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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the services are 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility. There is no indication that the enrollee would require skilled 
rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain his functional status.  The enrollee can receive 
further services at a lower 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is important to the enrollee so that they can 
return to their previous level of function. The Plan denied your request. The Plan says The services you need 
can be provided safely in other settings, for example, a skilled nursing facility, home with  
home health services or home with outpatient therapy. Under Medicare, the request 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 rehabilitation 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, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation does not 
support that she would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no 
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 
15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status.  The enrollee can receive further services at a lower 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative treatment of dental pain (D9110) and a limited oral 
evaluation (D140) provided on April 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe that the Plan should cover more. 
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 February 13, 2023, and February 14, 2023. Therefore, we decided that the Plan does not have to pay for palliative treatment of dental 
pain (D9110) and a limited oral evaluation (D140) provided on April 5, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for outpatient therapy services provided from April 6, 2023, to April 18, 
2023. 
 
You asked the Plan to pay for outpatient therapy services. You say that these services were medically necessary 
and appropriate. The Plan denied your request. The Plan says that these services must be re-billed with an 
appropriate modifier to show they were provided in excess of the allotted yearly therapy amount threshold. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide any documentation to support that the 
services at issue were provided in excess of the allotted yearly therapy amount threshold. In addition, the Plan 
did not provide any original claims for the services at issue. Without the original claims, we cannot verify how 
these services were billed. The Plan has not provided sufficient documentation to substantiate their denial in 
this case. Therefore, we decided that the Plan has to pay for outpatient therapy services provided from April 6, 
2023, to April 18, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TissueCypher Barretts Esophagus test (0108U) provided 
April 7, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the TissueCypher Barrett's Esophagus test 
was denied in error, and you are requesting it to be reprocessed and paid. The Plan denied your request. The 
Plan says the clinical value and effectiveness of TissueCypher Barretts Esophagus assay have not been 
demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the TissueCypher Barretts Esophagus test (0108U) provided April 7, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 29, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this provider is eligible for Medicare payment. 
The Plan denied your request. The Plan says this provider was excluded from federal programs at the time of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare payment may not be made for items or 
services furnished or prescribed by an excluded provider or entity. Federal funds shall not be used to pay for 
services, equipment or drugs prescribed or provided by a provider excluded by the Department of Health and 
Human Services (DHHS) Office of the Inspector General (OIG). OIGs List of Excluded Individuals and 
Entities (LEIE) includes all health care providers and suppliers that are excluded from participation in federal 
health care programs.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. The record shows that at the time of service, this provider 
was included on the DHHS OIGs LEIE, meaning Medicare payment cannot be made for these services. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on November 29, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show that you have complex 
rehabilitation needs that require frequent evaluation by a rehabilitation physician. The Plan says that the 
services needed may be provided safely in a lower level of care. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's medical record overall significantly complies with the various documentation requirements 
for IRF admission, the requested inpatient rehabilitation facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0156, G0299, G0300, Q5001) 
provided on December 22, 2022, to January 20, 2023. 
 You asked the Plan to pay for home health services. You say that you submitted the NOA but due to a software 
issue, it did not hit the system in time. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 22, 2022. The NOA was not received by the Plan. As more than 
30 days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services (G0156, G0299, G0300, 
Q5001) provided on December 22, 2022, to January 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
September 10, 2022, through September 12, 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 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 does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with report of a syncopal 
episode. His alcohol level was 330, and he was diagnosed with alcohol intoxication. He was alert and oriented. 
His vital signs were stable. There were no signs of withdrawal or any other acute condition that would be 
expected to require inpatient services that would likely have crossed two midnights. The documentation 
describes a stable patient where observation care would have been appropriate.  
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from September 10, 2022, through September 12, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac ultrasound provided on June 21, 
2023. 
 
You asked the Plan to waive the copayment for the cardiac ultrasound. You say that the services were not 
provided. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for outpatient diagnostic tests and therapeutic services. 
 
You have been asked to pay a $10 copayment for the cardiac ultrasound. This item/service falls within the 
outpatient diagnostic tests and therapeutic 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. The medical records show a cardiac ultrasound was provided on 
June 21, 2023. Therefore, we decided that the Plan does not have to waive the copayment for the cardiac 
ultrasound provided on June 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for opioid treatment program services May 18, 
2023. 
 
You asked the Plan to waive the cost share for opioid treatment program services. You say that you disagree 
with the cost share. 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 $650 deductible which applies to opioid treatment program services.  
 
The item or service you asked the Plan to waive the cost share for falls within the opioid treatment program 
services benefit category. You are being asked to pay $250 towards your $650 deductible. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $650 deductible which applies to 
opioid treatment program services. This cost sharing is a contractual obligation that had not been met at the 
time opioid treatment program services was received on May 18, 2023. Therefore, we decided that the Plan 
does not have to waive the cost share for opioid treatment program services May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220) or waive the coinsurance for a 
crown (D2750) provided on April 18, 2023, to May 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe that the Plan should pay for these 
services. The Plan denied your request. The Plan says these services have been processed correctly. 
 
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 D0220 was exhausted on date of service January 16, 2023. A 20% coinsurance was 
correctly applied to D2750.  Therefore, we decided that the Plan does not have to pay for intraoral imaging 
(D0220) or waive the coinsurance for crown (D2750) provided on April 18, 2023, to May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on June 6, 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 an 
occlusal guard (D9944) provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic-porcelain/ceramic (D6245) of tooth number 3 and a 
pontic-porcelain/ceramic (D6245) of tooth number 2 and 4 provided on February 28, 2023. 
 
You asked the Plan to pay for pontic-porcelain/ceramic (D6245) of tooth number 3 and a pontic-
porcelain/ceramic (D6245) of tooth number 2 and 4. You say that the procedure was done to reduce cost and 
save time. You also say that this should be an exception to the exclusions and limitations. The Plan denied 
your request. The Plan says these service codes are not listed as covered codes. 
 
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 pontic-
porcelain/ceramic (D6245) of tooth number 3 and a pontic-porcelain/ceramic (D6245) of tooth number 2 and 4 
provided on February 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (81003, 87086, 99283) 
provided on June 9, 2023. 
 
You asked the Plan to pay for the ER visit. 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 the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency room (ER) visit (81003, 
87086, 99283) provided on June 9, 2023.