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 these services are medically necessary. The Plan 
denied your request. The Plan says that the care you need is not complex enough and does not show it would 
cause excessive physical hardship for you to receive needed care in an outpatient basis or skilled nursing 
facility. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You have a fracture of your ankle. You are living in 
your home and do not have any problems requiring inpatient admission. Medical problems are stable. There are 
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record 
supports the need for physical and occupational therapy but does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup coded as D2950. 
 
You asked the Plan to pre-approve the core buildup. You say that the enrollee requires these services for his 
oral health. The Plan denied your request. The Plan says all services were approved aside from the core buildup 
which is not a covered benefit under the plan. 
 
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 
core buildup coded as D2950.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation and treatment to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve consultation and treatment. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent 
nor urgent to seek out-of-network care. The Plan says there are in-network specialists available to you that can 
provide the care and treatment you are requesting. The Plan says they have in-network specialists who are 
trained under a melanoma program with a sub-specialty in cutaneous malignancies, such as Merkel Cell 
Carcinoma. 
 
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 
consultation and treatment to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided it was not expected this enrollee would 
improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness 
to self or others, auditory or visual hallucinations and without aggressive behaviors. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question as the enrollee did not have any suicidal or homicidal thoughts, 
auditory or visual hallucinations or abnormal behaviors. The health plan's denial of continued inpatient 
psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond 
the dates in question as noted above as the enrollee was not a danger to himself or others and did not have any 
illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the 
date in question. It did not appear that the services for the dates in question were reasonably expected or 
medically necessary to improve the patient's condition or for the purpose of diagnosis. Our physician reviewer 
was unable to find an individualized treatment plan however the entire record is not present. It appears that the 
services were supervised and evaluated by a physician. Based upon review the records provided, this patient 
does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of September 9, 2020 forward and could have been treated in a lesser restrictive setting as he was not 
showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing 
any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee scooter. 
 
You asked the Plan to pre-approve the knee scooter. You say that after your upcoming knee surgery you cannot 
use crutches as it puts strain on your back. The Plan denied your request. The Plan says there is insufficient 
published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the 
medical necessity for these products. 
 
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 the knee scooter.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee's needs can likely be met in a lower level 
of care. 
 
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 is a female who presented to the hospital on 08/06/2020 for abdominal 
and scapular pain. Her hospitalization was complicated by a cardiac arrest with asystole for which she received 
CPR and was intubated. She failed extubation and subsequently a Trach was placed. She has now been 
extubated to Trach Collar on FiO2 28%. She has a PEG tube due to dysphagia. She had percutaneous drainage 
on 9/2/20 for a cystic pancreatic mass and still has a patent and functioning drainage tube in place. She has 
completed all antibiotics for a pneumonia and UTI. She lives with her husband and her PLOF was independent 
with a rolling walker. Her CLOF is max assist to total dependent. A Hoyer lift is recommended for transfers. 
On 9/8/20, both PT and OT notes stated that the enrollee needs a rehab facility. She is no longer on mechanical 
ventilation. 
 
The review has determined that the enrollee does not require services at the LTACH that are not available at 
the acute care hospital where she is currently receiving care. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the health plan. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: 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 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 based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but 
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy 
program. Based on the medical records provided there is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs help with eating and 
needs help to regain his strength. You say that you cannot care for the enrollee properly at home. The Plan 
denied your request. The Plan says SNF care 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled 
nursing service needs. There are identifiable skilled therapy service needs, in that the enrollee would benefit 
from occupational therapy. However, these occupational therapy service needs are not required on a daily 
basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis in a 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4342 x2) 
provided on February 24, 2020. 
 
You asked the Plan to pay for the scalings and planings. You say that the provider's office did not understand 
why only half of your visit was covered. You also say that the provider's office assured you that the price 
would be better than what you see on your Explanation of Benefits. The Plan denied your request. The Plan 
says this procedure is not covered by your plan. 
 
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 pay for the two 
periodontal scalings and root planings (D4342 x2) provided on February 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting, spine surgery 
only, through separate skin or fascial incision (CPT Code 20939). 
 
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found bone marrow aspiration remains experimental in spinal fusion surgery. More research is needed to show 
safety and efficiency. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration for bone grafting, spine surgery only, through separate skin or 
fascial incision (CPT Code 20939).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on February 19, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that the patient's provider sent the specimen to 
you for testing, so it should be authorized. The Plan denied your request. The Plan says unauthorized, non-plan 
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. 
 
Neither the provider in this case nor the provider who ordered the pathology services is a network provider 
with the Plan. The Plan had network providers available who could have provided 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 the 
pathology services provided on February 19, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that no beds are available at an in-network SNF. 
The Plan denied your request. The Plan says there are in-network options available. 
 
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 SNF services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Purewick external catheter. 
 
You asked the Plan to pre-approve a Purewick external catheter. You say that other systems, like indwelling 
catheters, have not worked and carry too high a risk. You say that the enrollee would benefit from the requested 
device which would lead to less need for emergency care of UTIs. The Plan denied your request. The Plan says 
that the requested device is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Purewick external catheter. Our 
reviewer says that the requested item is considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has urinary incontinence, neuromuscular dysfunction of the bladder and 
continuous leakage. The enrollee has had multiple UTIs, some resulting in hospitalizations for urosepsis. The 
request is consistent with the device and supplies of this urine collection system. The requested Purewick 
external catheter is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Purewick external catheter have been met. Therefore, we decided that the Plan 
has to pre-approve a Purewick external catheter.  
 
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 a dental core buildup for teeth 8 and 9. 
 
You asked the Plan to pre-approve the core buildups. You say that your broken tooth affects your eating. The 
Plan denied your request. The Plan says the service is not listed as a covered benefit. 
 
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. 
 
Although 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 a dental core 
buildup for teeth 8 and 9.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine provided on May 1, 2020. 
 
You asked the Plan to pay for the Tdap vaccine. You say that you did not know the vaccine was not covered 
under your Part B benefit. The Plan denied your request. The Plan says there is no indication of risk or acute 
injury justifying coverage under Part B benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tdap vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tdap vaccine. 
Therefore, we decided that the Plan does not have to pay for the Tdap vaccine provided on May 1, 2020.  
 
Benefits for Tdap vaccine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 24, 2020 to 
February 28, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for radiation therapy. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan offers coverage for certain out-of-network items and services using a Point-of-Service 
(POS) benefit. However, prior authorization must be obtained for out-of-network radiation therapy services to 
be covered by the POS benefit. 
 
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. 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 medical services provided on February 24, 
2020 to February 28, 2020 by an out of network (OON) provider.