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

 
We decided that the Plan does not have to pre-approve crowns for teeth 18 and 20 (D2740 x2). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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 December 22, 2020. 
Therefore, we decided that the Plan does not have to pre-approve crowns for teeth 18 and 20 (D2740 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim partial lower denture (D5821), a prefabricated 
abutments (D6056) for tooth #29, #30, #32, an implant supported to denture (D6113) for tooth #24, #25, #26, 
and #27, and an ineligible service (D9999) provided by an out-of-network provider on October 22, 2019, June 
24, 2020, July 7, 2021, and September 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says the dental services that were received on October 22, 2019, and 
June 24, 202, were from an out-of-network provider and are not covered by your supplemental benefits. The 
dental implants and an ineligible service on July 7, 2021, and September 29, 2022, were denied because they 
are not covered by the Plan. 
 
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. The implant supported denture and the ineligible 
service are not covered under the Plans dental benefits. Therefore, we decided that the Plan does not have to 
pay for an interim partial lower denture (D5821), a prefabricated abutments (D6056) for tooth #29, #30, #32, 
an implant supported to denture (D6113) for tooth #24, #25, #26, and #27, and an ineligible service (D9999) 
provided by an out-of-network provider on October 22, 2019, June 24, 2020, July 7, 2021, and September 29, 
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 enrollee is below baseline and requires close 
physician oversight. 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-network (OON) outpatient physical therapy 
services. 
 
You asked the Plan to pre-approve OON physical therapy. You say that you have medical urgency for an 
expedited appeal. You say you have constant headaches and neck pain and cannot take pain medication. The 
Plan denied your request. The Plan says you do not have coverage for an out-of-network provider or facility. 
 
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 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. Therefore, we decided that the Plan does not have to pre-approve 
out-of-network (OON) outpatient physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 4, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the outpatient service. You say that you do not remember being there or having a 
sinus infection. You say that you received a bill for $93.49. You also say that you would like to dispute this 
claim. 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 $65 
copayment for Urgently needed services.   
Review of the medical records provided verify that you were seen for this date of service at this provider. The 
Plan also verified that the services were urgent and the Plan is asking you to pay a $65 copayment for the 
urgently needed services. Your 2022 EOC states, enrollees must pay a $65 copayment for urgently needed 
services in a non-preferred facility. 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 the office visit provided on 
October 4, 2022, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollees needs cannot be met at a lower level of 
care. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met. 
 
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 was admitted for a fall with humerus fracture, pelvic fracture and acetabular fracture and had shoulder 
replacement surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. 
 
There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need therapy in an IRF setting. The Plan denied 
your request. The Plan says 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 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99284) provided on January 24, 
2023. 
 
You asked the Plan to pay for emergency room visit. You say that this was coded correctly. The Plan denied 
your request. The Plan says diagnosis code J70.5 is not an appropriate primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. The definition of diagnosis code J70.5 is respiratory conditions due to smoke 
inhalation. 
 
We asked our coder 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 emergency room visit. Our reviewer says that this code does 
not meet criteria for payment. Our reviewer found diagnosis code J70.5 should not be used as a first listed 
diagnosis according to guidelines. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of emergency room visit have not been met. Therefore, we decided that the Plan 
does not have to pay for an emergency room visit (99284) provided on January 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay at the inpatient psychiatric level of care 
from June 30, 2023, forward. 
 
You asked the Plan to pre-approve the continued stay. You say that the enrollee is not in stable condition. The 
Plan denied your request. The Plan says the continued stay at the inpatient psychiatric level of care is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued stay. Our reviewer says 
that the request for continued stay at the inpatient psychiatric level of care is not medically necessary. Our 
physician reviewer found the provided documentation indicates that the enrollee did not require inpatient 
mental health treatment beyond the dates in question as noted above as the enrollee was not a danger to 
themself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. Therefore, the reviewer found that the requested continued care is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continued stay have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continued stay at the inpatient psychiatric level of care from June 30, 2023, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet joint with image guidance (64493 x 2, 64494 x2). 
 
You asked the Plan to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet joint with 
image guidance. You say that this is medically necessary. The Plan denied your request. The Plan says the 
enrollee has not tried/failed 3 months of conservative therapy. 
 
The Plan follows Medicare rules. Medicare rules say that in order for thermal radiofrequency destruction of 
lumbar paravertebral facet joint nerves to be considered medically reasonable and necessary, patients must 
have pain present for minimum of 3 months with documented failure to respond to non-invasive conservative 
management. 
 
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 injection(s), diagnostic or therapeutic 
agent, paravertebral facet joint with image guidance. Our reviewer says that the service is not medically 
reasonable and necessary. Our physician reviewer found there is no documentation submitted that indicates the 
enrollee has completed 3 months of conservative therapy.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection(s), diagnostic or therapeutic agent, paravertebral facet joint with image 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), 
diagnostic or therapeutic agent, paravertebral facet joint with image guidance (64493 x 2, 64494 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient level of hospital care for a lumbar 
laminectomy. 
 
You asked the Plan to pre-approve inpatient level of hospital care for a lumbar laminectomy. You say that this 
is medically necessary. The Plan denied your request. The Plan says this is not medically necessary. The 
surgery can be performed at observation level. 
 
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 pre-approve inpatient level of hospital care for a 
lumbar laminectomy. Our reviewer says that the documentation does not support that the criteria for inpatient 
admission are met in this case. Our physician reviewer found you have been given medical clearance for the 
elective procedure and do not have identified unstable co-morbid conditions that would require a higher level 
of intervention post operatively. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient level of hospital care for a lumbar laminectomy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient level of hospital care for a lumbar 
laminectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (27447) provided on October 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the DRG payment. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. In this case, payment for the requested services is included in the 
facility payment. Based on this information, we decided that Medicare rules for coverage of the services have 
not been met. Therefore, we decided that the Plan does not have to pay for the services (27447) provided on 
October 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 9, 2022, 
to December 8, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the certification period is correct. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from November 9, 2022, to 
December 8, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that the enrollee is suffering from knee pain and is 
unable to walk. The Plan denied your request. The Plan says that the step therapy requirements have not been 
met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
required drugs Orthovisc or Supartz FX. Also, there is no indication that the Plan's required drugs would likely 
be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need more therapy than 15 minutes a day. You 
need acute inpatient therapy. The Plan denied your request. The Plan says 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 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 3, 2022, to 
April 1, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was 
submitted. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 3, 2022, to April 
1, 2022.