Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
 
 
We decided that the Plan does not have to pre-approve electronic connection identified with code E2311, 
expandable controller identified with code E2377, and expandable controller harness identified with code 
E2313. 
 
You asked the Plan to pre-approve electronic connection, expandable controller, and expandable controller 
harness. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an electronic connection, expandable controller, 
and expandable controller harnesses are only covered for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that E2377 Expandable Controller, E2313 
Expandable Controller Harness and E2311 Electronic Connection are requested to control power tilt, recline 
and power elevating leg rests through the joystick. The documentation does not show the need for these power 
options to be controlled through the joystick. The documentation shows that you have an upper limb strength of 
3-4 out of 5 and you are independent with feeding. The documentation supports that your strength and function 
are adequate for you to be able to control the power options using their own switches which are included in the 
allowance of these power options. Based on this information, we decided that Medicare rules for coverage of 
electronic connection, expandable controller, and expandable controller harness have not been met. Therefore, 
we decided that the Plan does not have to pre-approve electronic connection identified with code E2311, 
expandable controller identified with code E2377, and expandable controller harness identified with code 
E2313.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra Pen 30 MG/ML. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this drug has been APPROVED under the member's Medicare PART D Plan 
through/for December 31, 2021. 
 
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. Given our current information, this drug has been APPROVED under the member's Medicare 
PART D through/for December 31, 2021. For a Medicare Advantage & Part D drug plan (MAPD) like the 
member's, Part D can cover when: the pharmacy dispenses the drug to the member to self-administer, or to take 
it to the member's provider; or is given in a long term care facility (LTC); or is given in the member's home, or 
in assisted living- without an infusion pump. Part B covers in all other circumstances. Therefore, we decided 
that the Plan does not have to pre-approve Fasenra Pen 30 MG/ML.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310) with an out-of-network dental 
provider. 
 
You asked the Plan to pre-approve the dental service. You say that your face is swollen. You say that you are 
not able to eat. You say that you have an infection. You say that you need approval to see an out of network 
dentist because the closest in network provider is 6 to 8 hours away from you. The Plan denied your request. 
The Plan says the provider in this case is not a network provider. The Plan says that services provided out of 
network are not covered. The Plan also says there is a provider in network that can perform the root canal. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
consultation (D9310) with an out-of-network dental provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Facet Joint Injections (CPT Codes: 64495, 64494, 64493). 
 
You asked the Plan to pre-approve the injections. You say that the services are necessary. The Plan denied your 
request. The Plan says they reviewed the records and they show the member has longstanding low back pain. 
The Plan states the record sent by the provider indicates the member has chronic low back pain that has not 
responded adequately to prior conservative treatment. The Plan states an initial diagnostic medical branch 
block, performed on August 18, 2020, resulted in zero pain relief initially and upon the member's 9-week 
follow-up, the member reported 45% improvement in their pain although the pain had returned to its initial 
level by that time.
 
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 injections. Our physician reviewer 
found the documentation indicates that the enrollee did not experience greater than or equal to 80% relief of 
their primary (index) pain, lasting a time period consistent with the local anesthetic used from the initial 
diagnostic medial branch block. The review has determined that the medical records provided did not meet the 
requirements listed in the LCD for Medicare coverage. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Facet Joint Injections (CPT Codes: 64495, 64494, 64493).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sure Injections. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this is not covered by Medicare or 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 pre-approve Repatha Sure Injections.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee is too 
weak to participate fully in therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that you are at a total assist level for hygiene, and contact guard assist for sitting, standing, and mobility using a 
rolling walker. The complexity of your nursing, medical and rehabilitation needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. Your medical status 
does not appear to be stable enough for transfer to a rehab program. You are not eating, not feeling well, and 
there is discussion of a feeding tube placement which has not occurred. You may benefit from multiple 
therapies, but the documentation does not support that your functional and medical status can currently tolerate 
an IRF level of therapy. 
 
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
May 25, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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. 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 out of network physician 
services provided to the enrollee on May 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided, the health plan?s denial of LTACH coverage 
should be upheld. The enrollee is currently undergoing treatment at an ACH for multiple chronic medical 
conditions, including end-stage renal disease.  The enrollee is not intubated/ventilated. There is no evidence 
that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to 
provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee 
can remain at the current ACH until such time no acute services are required. The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing LTC needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the microslide consultation (88321) provided on June 22, 
2020. 
 
You asked the Plan to pay for the microslide. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says CPT 88321 has an MUE value of 1, but billed 2 units. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 88321 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the microslide have not been met. Therefore, 
we decided that the Plan does not have to pay for the microslide consultation (88321) provided on June 22, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on October 14, 2019, to 
October 16, 2019 by an out of network provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you did not know you needed 
authorization for out-of-network services. The Plan denied your request. The Plan says you did not request 
prior authorization. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services provided on October 14, 2019, to October 16, 2019 
by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided, the health plan?s denial of LTACH coverage 
should be upheld. The enrollee is currently undergoing treatment at an ACH for CoViD-19. The enrollee is not 
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that you require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. The clinical assessment in the 
case file does not support that you are reasonably expected to benefit from, and improve with, LTACH 
services. The clinical assessment does not support that you are stable for transfer. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120) and prophylaxis (D1110) 
provided on July 11, 2018. 
 
You asked the Plan to pay for the dental services. You say that you did not realized that you had dental 
coverage on your Medicare policy. You say that once you realized this, you gave your insurance information to 
your dental office. You also say that that is when the office submitted the claims. The Plan denied your request. 
The Plan says the services that you received are dental in nature. The Plan also says that routine dental services 
are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120) and 
prophylaxis (D1110) provided on July 11, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. 
The Plan says the stay 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 above. 
 
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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. The patient was admitted for confusion and was treated for a urinary 
tract infection. Medical conditions are stable. There are medical needs requiring inpatient admission. There are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient 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 
IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on January 30, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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. 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 physician services provided 
to the enrollee on January 30, 2020.