Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve WoundFix skin substitute. 
 
You asked the Plan to pre-approve WoundFix skin substitute. You say that the patient has not responded to 
conservative wound care for approximately 6 months. More aggressive treatment is medically necessary to 
prevent further damage and risk of infection. The Plan denied your request. The Plan says that there is no 
evidence to show that the patient's wound has failed to heal with standard wound care. As a result, the 
requested skin substitute is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 WoundFix skin substitute. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient has failed first line treatments. WoundFix skin substitute is needed to 
avoid an expensive procedure and its use is based on the community standard 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 WoundFix skin substitute have been met. Therefore, we decided that the Plan 
has to pre-approve WoundFix skin substitute.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 1, 2023, 
to March 24, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not made aware you would 
need to pay a copayment for the SNF stay. 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 $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $2,352 for a SNF stay ($196 per day x 12 days = $2,352). This item/service falls 
within the SNF care 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 SNF stay provided 
from March 1, 2023, to March 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biologic materials to aid in soft and osseous tissue 
regeneration (D4265) and bone graft at time of implant placement (D6104) provided on August 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says these services are not covered under the Plan's 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 the 
biologic materials to aid in soft and osseous tissue regeneration (D4265) and bone graft at time of implant 
placement (D6104) provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutmentincludes placement 
(D6057) and an implant supported porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested items are not covered under your 
supplemental dental policy.  
 
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 are not among 
those covered under this benefit.   
 
 
Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutmentincludes 
placement (D6057) and an implant supported porcelain/ceramic crown (D6065).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infrared therapy (97026) provided on November 9, 2022 to 
November 11, 2022. 
 
You asked the Plan to pay for Infrared therapy. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Infrared therapy is considered not reasonable and 
necessary and is non-covered. 
 
We looked at the file and Medicare rules. This service is non-covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of Infrared therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for Infrared therapy (97026) provided on November 9, 2022 to 
November 11, 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 would benefit from a high level of 
rehabilitation to regain their maximum strength. The Plan denied your request. The Plan says the enrollee does 
not meet the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat and a tub stool or bench. 
 
You asked the Plan to pre-approve a raised toilet seat and a tub stool or bench. You say that the requested items 
are medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature. Medicare rules also say that shower chairs are not covered 
because they are not primarily medical in nature. 
 
  While a raised toilet seat and a tub stool or bench may be appropriate for the enrollee, neither the Plan nor 
Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a 
raised toilet seat and a tub stool or bench.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265), and guided tissue regeneration - resorbable barrier, per site (D4266). 
 
You asked the Plan to pre-approve the biologic materials and guided tissue regeneration. You say that you 
cannot wait for the procedure and the doctor stated the sooner the better. The Plan denied your request. The 
Plan says any procedure that is not listed in the enrollees EOC sections are not covered. 
 
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 are not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous 
tissue regeneration, per site (D4265), and guided tissue regeneration - resorbable barrier, per site (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp vitality tests and dental consultation (D0460, D9310) 
provided on July 21, 2022. 
 
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 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 July 26, 2022. Therefore, 
we decided that the Plan does not have to pay for pulp vitality tests and dental consultation (D0460, D9310) 
provided on July 21, 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 will benefit from extensive therapy 
services and would benefit from the multidisciplinary approach. The Plan denied your request. The Plan says 
the enrollee does not meet the 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 continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement. However, the documentation doesnt support that they 
would meet criteria for admission to an acute inpatient rehabilitation facility. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 29, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell, 
could not get up after trying for two hours, and the emergency medical service arrived to help you get up. You 
also say that you cannot pay this bill and are hoping you might review the claim. The Plan denied your request. 
The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 29, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a dental consultation (D9310) provided on January 10, 
2023. 
 
You asked the Plan to pay more 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 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 a dental consultation (D9310) provided on 
January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an electroacoustic evaluation for hearing aid (92595), a binaural, 
behind the ear hearing aid (V5140), and an ear mold (V5264). 
 
You asked the Plan to pre-approve an electroacoustic evaluation for hearing aid (92595), a binaural, behind the 
ear hearing aid (V5140), and an ear mold (V5264). You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that based on your plan benefit, we found the request for hearing 
aids is not covered by Medicare. The Plan also says they are covered by your Medicaid provider. 
 
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. The record shows the enrollee was enrolled in this Plan as of January 1, 2023. 
The date the request for authorization was made is May 8, 2023. The EOC, which list hearing aid benefit that 
are not clearly defined as being Medicaid only. The Plan has not substantiated their denial reason that the 
enrollee did not have hearing aid benefits at the time of the request for authorization. Therefore, we decided 
that the Plan has to pre-approve an electroacoustic evaluation for hearing aid (92595), a binaural, behind the ear 
hearing aid (V5140), and an ear mold (V5264).  
 
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 procedure code 88360 billed for date of service October 31, 
2022.   
You asked the Plan to pay for procedure code 88360. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88360 is 6. The MAI value for this code is 3. You billed 9 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
88360 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88360 
billed for date of service October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the dental service. You say that you have seen the out-of-network provider 
for years and you would like to stay in your area. The Plan denied your request. The Plan says dental services 
from an out-of-network provider are not covered by your supplemental benefits. Also, there are in-network 
providers in your service area that are accepting new patients. 
 
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 are requesting 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. Therefore, we decided that the Plan does not have to pre-approve a dental 
visit to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the PT services. You say that you were not aware that prior authorization 
was required. The Plan denied your request. The Plan says network providers are available to render necessary 
care. 
 
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 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that Prolia helps treat the enrollee's osteoporosis. 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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drugs Ibandronate, Pamidronate and Zoledronic Acid. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you have frequent falls and have had prior 
cervical spine fusion. You have lumbar radicular symptoms. The medical necessity of the requested MRI 
thoracic spine has not been explained despite multiple attempts to obtain clarification. No thoracic spine x-ray 
is in the records and no electromyography (EMG) or other testing points to a thoracic spine problem. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the thoracic spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation, intraoral x-ray, and 
cleaning (D0150, D0210, D1110) provided on March 20, 2023, to March 23, 2023. 
 
You asked the Plan to pay more 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 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 a comprehensive oral evaluation, intraoral x-
ray, and cleaning (D0150, D0210, D1110) provided on March 20, 2023, to March 23, 2023.