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

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) for tooth #7 and #10, 
and an abutment supported to crown (D6058) for tooth #7, #8, #9, and #10. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for the enrollee to 
get a new implant fixed bridge. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because implants and all related services are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  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 
prefabricated abutment (D6056) for tooth #7 and #10, and an abutment supported to crown (D6058) for tooth 
#7, #8, #9, and #10.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 
18, 2023. 
 
You asked the Plan to pay for the ED services. You say that you have attached the documents and would like 
the claim reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be 
made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) provided on July 
14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this additional x-ray. 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 14, 2023. Therefore, we decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) 
provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) provided on July 5, 2023. 
 
You asked the Plan to pay for the dental service. You say that you broke your previous upper denture, and a 
new denture was necessary. The Plan denied your request. The Plan says the denial of payment for this service 
is correct, because dentures are not covered by the Plan. Also, it was verified that you were told prior to the 
date of service that dentures were 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
complete upper denture (D5110) provided on July 5, 2023.  
 
Your complaint about the Plans policy and the quality of service from the provider is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance without transport services received on July 
27, 2023. 
 
You asked the Plan to pay for the ambulance without transport services. You say that you were unaware that 
this wouldn't be covered and that you should have been made aware. The Plan denied your request. The Plan 
says without transport there are no payable charges. 
 
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 July 27, 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 without transport services received 
on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on May 1, 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. You say that you need to see a physician everyday and receive 
therapy so you can get better to go home. The Plan denied your request. The Plan says the services you need 
can be provided safely in other settings.  
 
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 is medically stable as described above and does not need PMR 
physicians supervision 3 times a week in an IRF. Document does not support necessity for admission to an 
IRF. The complexity of the enrollees medical, rehabilitation, and nursing needs. Combined complexity does 
not require acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. 
IRF admission is not necessary and is not reasonable. The enrollees rehabilitation needs can be safely provided 
in an alternate and low intensity setting such.  
 
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 pre-approve the complete denture - mandibular (D5120), and 
complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the new dentures you received do not fit. 
You also say that the doctor keeps having you come in for adjustments but they do not fit properly no matter 
how much they are grinded down and you want to return them.  The Plan denied your request. The Plan says 
your benefit for the complete denture - mandibular and maxillary 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 dentures was exhausted on date of service March 16, 2023. Therefore, we 
decided that the Plan does not have to pre-approve the complete denture - mandibular (D5120), and complete 
denture - maxillary (D5110).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you say that you disagree with the denial for the 
admission to an IRF. The Plan denied your request. The Plan says these services the enrollee needs can be 
provided safely in other settings. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollees condition is in fact complex and fragile, and there is every reason to expect that they will 
participate in and benefit from IRF-level services to include at minimum PT and OT for pre-prosthetic gait and 
ADL training, physician oversight of wound care and polypharmacy, and case manager coordination of any 
additional services that might be needed to make a sustainable return home, as well as avoid preventable 
readmissions to the acute hospital. Therefore, the requested inpatient rehabilitation facility admission is 
approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 pay for the SNF care provided from May 1, 2022, to May 11, 2022. 
 
You asked the Plan to pay for the SNF care. You say that you would like this claim reviewed and paid. The 
Plan denied your request. The Plan says this claim was submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that the claim for SNF care was not filed until June 15, 2023. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the SNF care provided from May 1, 2022, to May 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs from November 11, 2022, through 
November 12, 2022. 
 
You asked the Plan to pay for the medication. You say that your claim was filed incorrectly. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs from 
November 11, 2022, through November 12, 2022.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is in need of inpatient rehabilitation 
facility admission. 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 there is no active medical complexity. Records do not show acute rehab nursing 
needs. At the current functional level the enrollee needs physical and occupational therapy services. Document 
does not support necessity for admission to an IRF. The complexity of the enrollees medical, rehab, and 
nursing needs does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to 
rehabilitative care. The enrollees rehab needs can be safely provided in an alternate and low intensity setting.  
 
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: Favorable

 
We decided that the Plan has to pay for procedure code 80076 billed for date of service April 2, 2023.  
 
You asked the Plan to pay for procedure code 80076. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that payment for code 80076 is bundled into 
payment for code 80053. 
 
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, we have confirmed that code 80076 
is a column two code to column one code 80053 with a modifier indicator of 0. The column two code is 
therefore not payable. However, Medicare rules also 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. Specifically, the Plan has provided no claim showing that 
payment was made for procedure code 80053. Based on the claim submitted, Medicare billing criteria have 
been met. Therefore, we decided that the Plan has to pay for procedure code 80076 billed for date of service 
April 2, 2023.   
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the speech and hearing therapy (92507) and therapeutic 
activities (97539) provided from June 9, 2023, to June 11, 2023. 
 
You asked the Plan to pay for the speech therapy services. You say that the guidelines support that the enrollee 
should have been covered under their Medicare Advantage plan until the end of the month. You also say that Original Medicare became the primary coverage effective July 1, 2023. The Plan denied your request. The Plan 
says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the speech and hearing therapy (92507) and therapeutic 
activities (97539) provided from June 9, 2023, to June 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 19, 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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found On review of the available records, the enrollee with L1 fracture in TLSO as 
described above does not meet CMS coverage criteria for IRF admission. 
The enrollee is medically stable as described above and does not need PMR physicians supervision 3 times a 
week in an IRF. 
There is no active medical complexity. 
 No acute rehab nursing needs documented. 
At the current functional level (min A) the enrollee needs PT, OT and 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. 
Document does not support necessity for admission to an IRF. The complexity of the enrollees medical, rehab, 
and nursing needs (combined complexity does not require acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. 
IRF admission is not necessary and is not reasonable. 
The enrollees rehab needs can be safely provided in an alternate and low intensity setting such as in an SNF.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found documentation 
shows that you have had acute clinical status change however there is no specific ask from provider. The 
records do not show that "episodic" home health skilled nursing visits are required to effectively provide 
treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance 
program to maintain your condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90832) provided on July 27, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the service should be covered. The Plan denied 
your request. The Plan says the tax ID that the provider is associated with, found on the claim image is only 
showing that the provider is contracted for commercial lines of business only. The additional provider records 
found within the Plan's system are not showing active for the Medicare line of business and that it terminated in 
2022. Further the providers primary specialty is Counselor -Addiction (Substance Use Disorder) is not eligible 
to enroll in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832) provided on 
July 27, 2023.