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

 
We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images 
including bitewing with dental code D0210 provided on October 2, 2020. 
 
You asked the Plan to pay for the dental code D0210. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental code D0210 denied because the benefit 
maximum has been reached. The Plan says that this service is limited to once every three years and you 
received this service on August 20, 2019, which is less than three years ago. 
 
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, dental code D0210 is not covered in 
this case. The Plan covers this service once every three years and the file shows that you received this service 
on August 20, 2019, which is less than three years ago. Therefore, we decided that the Plan does not have to 
pay for the intraoral-complete series of radiographic images including bitewing with dental code D0210 
provided on October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure (LAAC) 
using the Watchman device. 
 
You asked the Plan to pre-approve the requested LAAC procedure. You say that you have been using blood 
thinners which cause you to feel unwell. This also causing issues with bleeding and bruising easily. You wish 
to have this procedure so that you can discontinue the use of blood thinners. The Plan denied your request. The 
Plan says you do not have any complications which prevent you from remaining on blood thinners. This means 
that the Medicare criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC is considered reasonable and necessary for 
patients with atrial fibrillation for whom long-term anticoagulation is not indicated. 
 
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 requested LAAC procedure. Our 
reviewer says that the requested procedure does not meet NCD criteria and is not found to be reasonable and 
necessary in this case. Our physician reviewer found the patient is a 72-year-old male with a history of 
hypertension, hyperlipidemia, mitral regurgitation and persistent atrial fibrillation. The records document the 
patient is prescribed Xarelto with easy bruising, but no serious bleeding side effects reported.  
 
In this circumstance, atrial fibrillation treatment options include continuation of anticoagulation or 
percutaneous left atrial appendage exclusion using a Watchman device. The Watchman device was FDA 
approved in 03/2015 based on one trial (PREVAIL) with lower complication rates compared to original trials. 
However, longer term follow-up of that trial demonstrated an additional 8 strokes, all in the arm that received 
the Watchman device, calling into question its long-term efficacy. Taking these additional data into account, 
the Watchman device has failed to demonstrate non-inferiority to warfarin. A recent meta-analysis also 
reported a similar all-cause stroke rate between the two groups. Therefore, the Watchman device should still be 
considered investigational in patients who are tolerating anticoagulation without major bleeding side effects or 
evidence of recurrent strokes, such as with this patient.  
 
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 requested LAAC procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve percutaneous left atrial appendage closure (LAAC) using the Watchman 
device.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve home health aide services. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
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 Plan states that the services are not medically necessary; however, there are 
no medical records for review. Without medical records, a determination based on medical necessity cannot be 
supported. Therefore, we decided that the Plan has to pre-approve home health aide 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission 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 enrollee was admitted to the current acute care hospital with septic shock, acute 
kidney injury, and complex wounds after stopping outpatient wound care visits on their own. The enrollee was 
treated with wound care, antibiotics for bacteremia, and multiple blood transfusions. Antibiotics have since 
been completed and he is not a candidate for flap procedure. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Therefore, the enrollee does 
not meet criteria for the requested admission. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transport mileage (A0170). 
 
You asked the Plan to pre-approve the additional mileage. You say that the additional mileage is medically 
necessary. The Plan denied your request. The Plan says there is a fifty -mile limit per trip. The number of trips 
for the plan benefit have already been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation up to fifty miles from the pickup location.  
 
We looked at your request, the records in the case file, and the rules. The request is for a trip that is 264 miles. 
The plan benefit is limited to fifty miles. Based on this information, we decided that the Plan's rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine transport mileage (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
reveals that you cannot enter bedrooms and bathrooms with a power scooter to complete MRADLs in the 
home. Therefore, a heavy duty group-2 powered wheelchair is more appropriate as it has a smaller turning 
radius that can allow access to all rooms of the home and may be safer with transfers. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on December 6, 2019. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim does not include the required value code 85 for the county where the service was rendered. 
Therefore, we decided that the Plan does not have to pay for the home health services provided on December 6, 
2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says needs can be in the current inpatient rehab facility, at home, or in long-term care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity 
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair. 
 
You asked the Plan to pre-approve recliner. You say that this is the only way you can sleep or get up after 
having surgery. The Plan denied your request. The Plan says the denial of authorization for this item is correct, 
because this item is not primarily medical in nature and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a recliner chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an implantable loop recorder is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee had a stroke in 2017 and 
possible patent foramen ovale. The clinic note dated November 25, 2020, documents he is feeling well with no 
palpitations. The remote stroke is not documented to be cryptogenic. In addition, if there is concern for atrial 
fibrillation contributing to a stroke then external off-line event recording would be the most appropriate initial 
evaluation. The records do not support the medical necessity for routine monitoring with an implantable loop 
recorder 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CPAP device provided on March 13, 2019. 
 
You asked the Plan to pay for the CPAP device. The Plan denied your request. The Plan says there is no valid 
referral for this service. 
 
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 
CPAP device. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for a CPAP device provided on March 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short-term acute 
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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 long-term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiothoracic surgeon. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is fragile following open heart 
surgery. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network cardiothoracic surgeon.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee required minimal assistance 
for grooming. The enrollee required minimum/maximum assistance for upper body and lower body dressing. 
The enrollee required maximum assistance for bed rolling, sitting up, and laying down. The enrollee required 
maximum assistance times three to stand up. The documentation does not support that the enrollee requires the 
specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and 
effectively provide medically necessary and reasonable treatment. The documentation does not support that 
skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does 
not require the necessary services on an inpatient basis, at a SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
provided on August 18, 2020. 
 
You asked the Plan to waive the copayment for EGD. You say that you did not have a say in this procedure and 
did not know it would result in a copayment. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
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 $250 
copayment for EGD at an outpatient hospital.  
 
You have been asked to pay $250 copayment for EGD. EGD falls within the Outpatient 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 copayment for an esophagogastroduodenoscopy (EGD) provided on 
August 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission to a SNF. You say that the enrollee needs SNF care. The Plan 
denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 admission to a SNF. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled 
nursing service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not 
require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 the admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the admission to a skilled nursing facility (SNF).