Persius/hicric huggingface dataset:
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 admission into an IRF is medically necessary. 
The Plan denied your request. The Plan says you do not meet 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 you were admitted for surgical management of a small bowel obstruction. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 sensor.  
You asked the Plan to pre-approve the Freestyle Libre Kit 2 sensor. You say that asdfasdf The Plan denied your 
request. The Plan says a continuous glucose monitor is covered under Medicare only if a member with diabetes 
is on insulin or has documentation of history of problematic low blood sugars. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for 
coverage of the Freestyle Libre Kit 2 sensor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre Kit 2 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial upper denture (D5213) provided on March 27, 2023. 
 
You asked the Plan to pay for the dental service. You say that your previous denture was not made properly, 
and you would like the Plan to cover the new denture. 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 the Plan paid for a partial upper denture (D5225) on September 15, 2022; therefore, your benefit for the 
requested item or service was exhausted on the date of service of September 15, 2022. Therefore, we decided 
that the Plan does not have to pay for a partial upper denture (D5213) provided on March 27, 2023.
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 the criteria for admission. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on April 5, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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.  
 
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. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns and pontics (D6750, D6240) provided on 
March 7, 2023.  
 
You asked the Plan to pay for retainer crowns and pontics. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 retainer 
crowns and pontics (D6750, D6240) provided on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft (D7953) provided on March 6, 2023. 
 
You asked the Plan to pay for bone replacement graft. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 bone 
replacement graft (D7953) provided on March 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electroencephalogram (EEG) procedures to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve EEG procedures. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services 
have not been met. 
 
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 
electroencephalogram (EEG) procedures to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug, Injection, ocrelizumab, 1 mg (J2350) 
 
You asked the Plan to pre-approve drug, Injection, ocrelizumab. You say that the drug is medically necessary 
for the enrollee. The Plan denied your request. The Plan says requested drug, Injection, ocrelizumab is not 
medically necessary. Compendia and literature reviewed all indicate that Ocrevus is to treat the enrollee with 
relapsing forms of multiple sclerosis (including relapsing-remitting disease, active secondary progressive 
disease, and clinically isolated syndrome) or primary progressive multiple sclerosis. There is no documentation 
that show enrollee has one of these diagnoses. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve drug, Injection, ocrelizumab. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drug, Injection, ocrelizumab have not been met. Therefore, we decided that the 
Plan does not have to pre-approve drug, Injection, ocrelizumab, 1 mg (J2350)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2335) and crown (D2740) 
provided on February 27, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were under the belief that you had not 
exhausted your benefit as of February 2023. 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 27, 2023. 
Therefore, we decided that the Plan does not have to pay more for the resin-based composite (D2335) and 
crown (D2740) provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve the crown. You say that your mouth is causing you pain. The Plan denied 
your request. The Plan says only the services listed in the Plans Comprehensive Dental Plan Information guide 
on the Patient Charge Schedule are covered by 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 pre-approve a 
crown - porcelain/ceramic (D2740).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 for date of service April 10, 2023. 
 
You asked the Plan to pay for procedure code 99309. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. Medicare rules say that Modifier 25 may be appended to a E&M CPT 
code to indicate that the E&M service is significant and separately identifiable from other services reported on 
the same date of service. 
 
We looked at the file and Medicare rules. Review of the file shows that the reporting of a separate E&M 
service for the work associated with the decision to perform a minor surgical procedure regardless of whether 
the patient is a new or established patient is not covered. This means code 99309 is not payable as billed. Based 
on this information, we decided that Medicare rules for coverage of procedure code 99309 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99309 for date of service April 10, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92004) provided on February 27, 
2023.  
You asked the Plan to pay for a medical eye examination (92004). You say that you were informed you just 
needed a referral from your primary care provider (PCP). The Plan denied your request. The Plan says you 
received non-routine vision services with a provider who is not a participating Plan provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $0 copayment for a routine examination with a Plan provider. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $0 copayment for a routine examination 
with a Plan provider. The record shows that this was a non-routine examination by a non-participating 
provider. Based on this information, we decided that the Plan's rules for coverage of  a medical eye 
examination (92004) have not been met. Therefore, we decided that the Plan does not have to pay for a medical 
eye examination (92004) provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an oral evaluation (D0120) and prophylaxis (D1110) 
provided on January 17, 2023 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the OON dental services. You say that your coverage should allow $1,000 
worth of benefit. You say you would like to appeal the lack of coverage and charges. 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.  
 
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. 
Therefore, we decided that the Plan does not have to pay more for an oral evaluation (D0120) and prophylaxis 
(D1110) provided on January 17, 2023 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), panoramic radiographic image (D0330), erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated (D7210), interim partial denture (including 
retentive/clasping materials, rests, and teeth), maxillary (D5820), 2D oral/facial photographic image obtained 
intra-orally or extra-orally (D0350), and unspecified orthodontic procedure, by report (D8999), provided on 
March 6, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0150, D0330, D7210, D5820, D0350 
and D8999. You say that the provider did not do their due diligence in confirming that the services being 
rendered would all be covered. The Plan denied your request. The Plan says your benefit for the comprehensive 
oral evaluation D0150 and panoramic radiographic image D0330 has already been exhausted. The Plan also 
says that dental services codes D7210, D5820, D0350 and D8999 are not covered under the Plans 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 services D7210, D5820, 
D0350 and D8999 are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the dental services codes D7210, D5820, D0350 and D8999 provided on March 6, 2023.  
The record shows your benefit for the comprehensive oral evaluation D0150 was exhausted on date of service 
July 15, 2022. The record shows the panoramic radiographic image D0330 was exhausted on this claim. You 
received an intraoral - complete series of radiographic images D0210 which shares the frequency. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and  panoramic radiographic image (D0330) provided on March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
22, 2023. 
 
You asked the Plan to pay for the dental services. You say that it has more than six months from your last 
cleaning. 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 August 7, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on March 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 2, 2022, to 
December 6, 2022. You asked the Plan to pay for the home health services. You say that the submitted records support the home 
health services and you ask to please reprocess the claim for payment. 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 2, 2022. The NOA was not received by the Plan until January 
24, 2023. 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 provided 
on December 2, 2022, to December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a limited oral evaluation (D0140) provided 
on March 17, 2023. 
  You asked the Plan to waive the copayment for the dental service. You say that you did not receive the services 
and the provider billed the dental service in error. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. Also, the provider and the dental records that were received the proper code was billed 
for the service that was rendered. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 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. Your contract with the Plan clearly says that you must pay a $25 copayment for each preventive 
dental service visit.  
 
You have been asked to pay a $25 copayment for the dental service. 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 waive the copayment for a limited oral evaluation 
(D0140) provided on March 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #26 provided on March 6, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you were not told you had to pay for the 
procedure, and it should be covered because the crown was covered. The Plan denied your request. The Plan 
says the denial of payment for this service is correct, because the core buildup is 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #26 provided on March 6, 2023.