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

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to noble metal (D6242) Tooth 
#28 and 30 and retainer crown - porcelain fused to noble metal (D6752) Tooth #27, 29 and 31. 
 
You asked the Plan to pre-approve dental services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the requested services do not meet criteria for a bridge. 
  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 dental 
services when the services are medically necessary and reasonable. This benefit includes pontic - porcelain 
fused to noble metal (D6242) and retainer crown - porcelain fused to noble metal (D6752) but is limited to 
once per 60 months. 
 
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 dental services. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the Plan criteria has not been met. As the 
missing teeth are two posterior teeth, the Plan would not provide coverage for a bridge under its provisions. 
 
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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pontic - porcelain fused to noble metal (D6242) Tooth #28 and 30 and retainer crown - 
porcelain fused to noble metal (D6752) Tooth #27, 29 and 31.
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 currently meets the LTACH 
admission criteria. The Plan denied your request. The Plan says the enrollee can remain in the current acute 
care location until such time no further acute level care is needed. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve US-IGRT. You say that this is appropriate and 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 US-IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found using ultrasound on a daily basis is not unreasonable, but is not necessary. Therefore, this 
would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of US-IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ultrasound guided radiation therapy (US-IGRT).
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. The Plan denied your request. The Plan says the 
services requested do not meet the requirements for approval, the enrollee needs continued treatments and care 
that can only be given in a hospital setting, when ready to leave the hospital, services can safely be receive in 
another setting, at a Skilled Nursing Facility (SNF) or at home with home health services. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
 
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 based on current condition the enrollee meets full 
inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee does not have complex 
medical and intensive rehabilitation needs requiring supervision by a rehabilitation physician and an intensive 
and coordinated interdisciplinary team in a resource intensive inpatient hospital environment. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 2. 
 
You asked the Plan to pre-approve the FreeStyle Libre Kit 2. The Plan denied your request. The Plan says the 
enrollee does not require insulin three or more times daily. 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the FreeStyle Libre Kit 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a FreeStyle Libre Kit 2.
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. The Plan denied your request. The Plan says the enrollee does not 
meet all of the requirements based on guidelines and the information we have, 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 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (codes 83970, 82728, 83540, and 
83550) related to end-stage renal disease (ESRD) provided on December 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (codes 83970, 82728, 83540, and 83550) related to end-stage 
renal disease (ESRD) provided on December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (codes 82728, 83540, and 83550) 
related to end-stage renal disease (ESRD) provided on November 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (codes 82728, 83540, and 83550) related to end-stage renal 
disease (ESRD) provided on November 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic resonance imaging, spinal canal, and 
contents, lumbar; without contrast material (72148). 
 
You asked the Plan to pre-approve a Magnetic resonance imaging, spinal canal, and contents, lumbar; without 
contrast material (72148). The Plan denied your request. The Plan says the enrollee's clinical condition does not 
meet the criteria for the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 Magnetic resonance imaging, spinal 
canal, and contents, lumbar; without contrast material (72148). Our reviewer says that the service is not 
medically necessary. Our physician reviewer found there was no documentation of progressive neurological 
deficits or new deficits noted. At this time, the request for a lumbar MRI exam is not medically 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 a Magnetic resonance imaging, spinal canal, and contents, lumbar; without contrast material (72148) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Magnetic resonance imaging, spinal canal, and contents, lumbar; without contrast material (72148).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve at home physical therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve at home physical therapy. You say that the enrollee is unable to find in-
network care that can provide the desired services on time and close to their home. The Plan denied your 
request. The Plan says the service can be provided by an in-network provider. 
 
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 
at home physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (codes 82728, 83540 and 83550) 
related to end-stage renal disease (ESRD) provided on August 22, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (codes 82728, 83540 and 83550) related to end-stage renal 
disease (ESRD) provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required tooth #30 
(D2950). 
 
You asked the Plan to pay for the core buildup, including any pins. You say that without the build-up/posts, 
you are not able to receive the crown and you are in pain. You also say that having the crown will help prevent 
bleeding when you brush and floss your teeth. The Plan denied your request. The Plan says this service is not 
covered under your benefit 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. 
  
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 core 
buildup, including any pins when required tooth #30 (D2950).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (codes 82728, 83540 and 83550) 
related to end-stage renal disease (ESRD) provided on December 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (codes 82728, 83540 and 83550) related to end-stage renal 
disease (ESRD) provided on December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the lab services and the radiology services 
provided by an out-of-network provider from August 19, 2022, to November 14, 2022. 
 
You asked the Plan to waive the cost sharing for the lab services and the radiology services. You say that you 
were not aware that the provider was out-of-network. 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 $750 deductible, which applies to out-of-network lab services and 
radiology services. Your contract with the Plan also says that you must pay 50% of the total cost for out-of-
network Medicare-covered outpatient x-ray services, lab services, and radiology services. 
 You have been asked to pay a total of $548.82 toward your deductible for the lab services and the radiology 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to out-of-network outpatient diagnostic tests and therapeutic services and supplies. 
This cost sharing is a contractual obligation that had not been met at the time the lab services and the radiology 
services were provided from August 19, 2022, to November 14, 2022. 
 
You have also been asked to pay 50% coinsurance of the allowed amount for each lab service and radiology 
service. These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that you have been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation that you agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the cost share for the lab services and radiology services 
provided by an out-of-network provider from August 19, 2022, to November 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to have rehabilitation services. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for IRF 
admission. 
 
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 enrollee is medically improving with all comorbid conditions being stable 
and does not need physical medicine and rehabilitation physician's supervision 3 times a week in an IRF. At the 
current low functional level, the enrollee does not need 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 Documentation does not support necessity for admission to an IRF. The complexity of the enrollee's 
nursing, rehabilitation, and medical, needs (combined complexity) does not require an acute hospital inpatient 
rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the enrollee may benefit from 
physical therapy and occupational therapy, the enrollee's rehabilitation needs can be provided in a lower 
intensity and alternate 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 the IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requested service is not medically necessary for the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules say that proton beam therapy is only covered under certain 
medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of invasive urothelial carcinoma of the bladder with squamous 
differentiation. He underwent a radical cystoprostatectomy with ileal conduit. He developed recurrent cancer 
involving bilateral inguinal lymph nodes and the urethral stump (pathologically confirmed high grade urothelial 
carcinoma). Standard therapy with photons is considered the standard of care. There is insufficient prospective, 
long-term clinical data available to determine whether or not proton beam radiation therapy for bladder cancer 
is superior, inferior, or equivalent to external beam radiation or intensity modulated radiation therapy (IMRT) 
with regards to safety and efficacy. Therefore, proton beam therapy is not medically necessary in this case. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.