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 enrollee has Parkinson's disease, and the 
requested facility offers Parkinson's treatment. They can monitor the enrollee's condition as well as provide 
physical therapy to help the enrollee walk again due to the fall. The longer the enrollee sits without movement 
the longer the enrollee will continue to decline. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility (IRF) services you are requesting do not meet the requirements for approval. 
 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. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the step therapy 
criteria 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 Synvisc-One. Our reviewer says that 
Synvisc-One is not medically reasonable and necessary in this case. Our physician reviewer found that there is 
no indication that the enrollee has tried and failed the required drug(s). Based on the medical records provided 
and the Medicare-approved major drug compendia, there is no indication that the Plan's required drug(s) would 
likely be less effective and/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 Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a pontic (D6241) for tooth #21 and a retainer crown (D6751) for 
tooth #20 and #22. 
 
You asked the Plan to pre-approve the dental services. You say that the requested bridge is medically 
necessary. The Plan denied your request. The Plan says that the denial of authorization for these services is 
correct, because the coverage criteria for a bridge was not met. 
 
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 the dental 
services when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the pontic (D6241) for tooth #21 and a retainer crown (D6751) for teeth #20 and #22 are medically 
necessary. Our physician reviewer found that a panoramic x-ray shows that teeth #19, #21, #30, and #31 are 
missing in the lower jaw. The enrollee is also missing tooth #1, #14, and #15 in the upper jaw. There was no 
narrative included that shows the proposed dental treatment plan for the enrollee to address other issues in the 
mouth. There is a failing bridge noted on the lower right side of the jaw that will need to be addressed and 
treated. There is an existing dental bridge noted from teeth #20 to #22. The ADA Claim Form included states it 
is recommended for a new bridge for teeth #20 to #22 due to open margin and chipped porcelain on tooth #22. 
The panoramic x-ray shows possible decay or large open margins underneath the bridge on teeth #20 and #22. 
Because the enrollee has an existing bridge with defects or decay, it is medically reasonable to replace the 
bridge. Based on the information provided, a pontic-porcelain fused to predominantly base metal (D6241) for 
tooth #21 and a retainer crown-porcelain fused to predominantly base metal (D6751) for teeth #20 and #22 are 
medically reasonable to treat the issues in these teeth. 
 
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 the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a pontic (D6241) for tooth #21 and a retainer crown (D6751) for tooth #20 and #22.  
  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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam computed tomography (CT) capture and 
interpretation with limited field of view-less than one whole jaw (D0364), cone beam CT capture and 
interpretation with field of view of both jaws; with or without cranium (D0367), oral hygiene instructions 
(D1330), surgical placement of an implant body: endosteal implant for tooth number 7 (D6010), and surgical 
access to an implant body for tooth number 7 (second stage implant surgery) (D6011). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve cone beam 
computed tomography (CT) capture and interpretation with limited field of view-less than one whole jaw 
(D0364), cone beam CT capture and interpretation with field of view of both jaws; with or without cranium 
(D0367), oral hygiene instructions (D1330), surgical placement of an implant body: endosteal implant for tooth 
number 7 (D6010), and surgical access to an implant body for tooth number 7 (second stage implant surgery) 
(D6011).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 07, 2023. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the lab services provided 
on June 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical assistant services provided on August 17, 2023. 
 
You asked the Plan to pre-approve surgical assistant services. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says these codes are not payable. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 26410, 13132, and 11044. The Medicare Fee Schedule Database contains 
a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant 
surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare 
coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgical assistant services provided on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement procedure provided on July 24, 2023. 
 
You asked the Plan to pay for the debridement procedure. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the debridement 
procedure provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
September 5, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that the service should be covered by 
the plan because you were seen by an in-network provider. The Plan denied your request. The Plan says this 
service is not listed as 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic 
radiographic image (D0330) provided on September 5, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the colonoscopy on May 19, 2023.  
 
You asked the Plan to waive the cost share for the colonoscopy. You say that the service should be covered at 
100%. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance of the approved amount. The annual deductible applies for outpatient services. There are three 
coinsurance amounts of $21.42, $51.93 and $11.21. There are two deductible amounts of $192.81 and $357.11. 
For the service it's $21.42 + $51.93 + $11.21 + $192.81 + $357.11 = $634.48. Therefore, results in the total 
cost sharing amount of $634.48. 
 
You have been asked to pay a $634.48 cost share for the colonoscopy. This item/service falls within the 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 cost share for the colonoscopy on May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) provided on August 16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were unaware this provider was out-
of-network. 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 crown (D2740) provided on August 16, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services rendered from July 14, 2023, to August 
12, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim has been re-grouped. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We asked our reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that the initial skilled nursing (SN) 
visit on July 14, 2023 claims that the enrollee is dependent for upper body dressing and dependent for toilet 
transfers. However, there is no actual documentation (physical therapy, occupational therapy, or home health 
aide) of dressing or toileting ability. As such, there is no evidence to support these claims. 
 
We looked at this coder's review, the file, and Medicare rules. 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 home health services rendered from July 14, 2023, to August 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code G0483) rendered on 
February 13, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was incorrect billing. 
 
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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided records in this case 
document that only 21 drug classes were tested: 
 
1. Amphetamines 
2. Sertraline Antidepressants, serotonergic class 
3. Antidepressants, Tricyclic and other cyclicals 
4. Benzodiazepines 
5. Buprenorphine 
6. Cocaine 
7. Fentanyls 
8. Heroin metabolyte 
9. Ketamine and Norketamine 
10. Methadone 
11. Methylenedioxyamphetamines 
12. Methylphenidate 
13. Opiates 
14. Opioids and opiate analogs 
15. Oxycodone 
16. Phencyclidine 
17. Propoxyphene 
18. Sedative Hypnotics (nonbenzodiazepines) 
19. Skeletal muscle relaxants 
20. Tapentadol 
21. Tramadol 
 
The records support that G0482 is the more appropriate code to use, based on the drug class count. 
 
We looked at this coder's review, the file, and Medicare rules. 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 laboratory services (procedure code G0483) rendered on February 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home or residence visit (99350) and nail debridement 
(11721) provided on July 20, 2023, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for home or residence visit and nail debridement. You say that you would like the 
medical records which prove medical necessity to be reviewed, and this claim to be reprocessed for payment. 
You also say that the patient is in an assisted living facility. The Plan denied your request. The Plan says the 
treating provider is not a network provider with the Plan. The Plan also says that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home or residence visit (99350) and nail 
debridement (11721) provided on July 20, 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 crown (D2740) provided on July 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your annual dental allowance amount 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 14, 2023. The 
claim for August 14, 2023 was processed prior to the claim for July 6, 2023. Therefore, we decided that the 
Plan does not have to pay for a crown (D2740) provided on July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) for tooth #15 provided on 
August 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency service due to severe 
pain and extreme root sensitivity. You say you were in too much pain to wait until your next six month visit. 
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 17, 2023 when 
you received a resin-based composite for tooth #14. Therefore, we decided that the Plan does not have to pay 
for a resin-based composite (D2391) for tooth #15 provided on August 17, 2023.