Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has the option to accept placement in a SNF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture and non-surgical management of a wrist fracture after a fall. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for gastrointestinal bleeding. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission. 
 
You asked the Plan to pre-approve inpatient admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 inpatient admission. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is undergoing a planned elective reverse total shoulder arthroplasty with 
tenodesis of the long tendon of the biceps. The enrollee is medically stable and will be provided medical 
clearance to undergo this elective procedure. The procedures are currently approved as an ambulatory 
procedure. Therefore, the enrollee does not meet criteria for the requested inpatient 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 inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hammertoe surgery provided on 
October 26, 2020. 
 
You asked the Plan to waive the copayment for the hammertoe surgery. You say that you should not be 
responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay the 
correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $345 
copayment for surgery services at an in-network outpatient hospital.  
 
You have been asked to pay a $345 copayment for the hammertoe surgery. The hammertoe surgery 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 the hammertoe surgery 
provided on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, 
K0553).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT, soft tissue neck; with contrast material(s) (Current 
Procedural Terminology (CPT) code 70491) CT, thorax, diagnostic; with contrast material(s) (71260), and CT, 
abdomen and pelvis; with contrast material(s) (74177). 
 
You asked the Plan to pre-approve the CT scans. You say that this says imaging does not evaluate blood 
disorders such as low blood counts and myeloproliferative disorders. You state you have chronic lymphocytic 
leukemia/Lymphoma, this is restaging for lymphoma for weight loss and larger nodes in the neck. You state 
they are listing the incorrect diagnoses for the denial. You state with these new symptoms, scans are needed to 
determine further treatment planning and evaluation. The Plan denied your request. The Plan says it is unclear 
how your management will be altered. The Plan states you are not being treated, and you have declined all 
other cancer screening procedures. The Plan states your weight loss is intentional, and there is no result for a 
positron emission tomography (PET) scan showing initial staging. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scans. Our physician reviewer 
found the review indicates that there is no specific clinical rationale for the requested CT, soft tissue neck; with 
contrast material(s) (CPT code 70491) CT, thorax, diagnostic; with contrast material(s) (71260), and CT, 
abdomen and pelvis; with contrast material(s) (74177). You are not being treated. You have declined all other 
cancer screening procedures. Your weight loss is intentional. There is no result for a PET scan showing initial 
staging. The review has determined that the requested CT scans are not medically necessary or reasonable. 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 CT scans have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT, soft tissue neck; with contrast material(s) (Current Procedural Terminology (CPT) 
code 70491) CT, thorax, diagnostic; with contrast material(s) (71260), and CT, abdomen and pelvis; with 
contrast material(s) (74177).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced knee/foot, rotational 
unit, and special liner for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request for a K3 microprocessor knee and foot does not meet the criteria of being 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical progress notes from the treating physician do not document a medical need for this request. 
The L5986 rotational unit is not medically necessary as the advanced foot is not medically necessary. The 
documentation indicates the enrollee uses an assistive device for ambulation and was recently admitted for 
heart failure. The physician documentation does not support a K3 functional level. The physician objective 
exam documentation does not reveal evidence of the need for a custom liner. The requested items exceed the 
patient's medical need are are not medically 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an advanced knee/foot, rotational unit, and special liner for the 
enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided on August 29, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you would like the 
transportation services to be covered in full. You say this was an emergency and there was no other option to 
transport the enrollee to the hospital. The Plan denied your request. The Plan says you have been asked to pay 
the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $250 copayment for each one-way Medicare-covered ground trip.  
 
The enrollee has been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within 
the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance ride provided on August 29, 2020.
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 enrollee is in need for intense physical therapy. 
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 in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for weakness, anemia, and a urinary tract infection. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the 
lower right and lower left quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. You say that you would like these services 
approved for coverage. The Plan denied your request. The Plan says this service is only cover 2 times in a 24 
month period. The Plan also says that you have already had 2 of these services done in that time period. 
 
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, periodontics, either code D4341 or 
code D4342, are limited to up to 2 quadrants every 24 months. The record shows that you had periodontal 
scalings and root planings (D4341) of the upper right and upper left quadrants approved on February 2, 2021, 
and your periodontic benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve periodontal scalings and root planings (D4341) of the lower right and lower left quadrants.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery. 
 
You asked the Plan to pre-approve Vertiflex Superion device placement surgery. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 Vertiflex Superion device placement 
surgery. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you were being treated for spinal stenosis lumbar region 
with neurogenic claudication. Past surgical history was positive for hemilaminectomy of L4-L5 in 1981, 
compression fracture status post kyphoplasty at L3 an dL4 levels in 2017. Conservative treatment had included 
medications, ice/heating pads, physical therapy, facet injections, and epidural steroid injections. FDA 
contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately 
addressed in the medical records. Detailed documentation is not evident regarding discussion of spinal 
instability on flexion/extension films and no discussion of scoliosis/Cobb angle. There is no discussion 
indicating that a DEXA scan has demonstrated the lack of significant osteoporosis. Therefore, you do not meet 
criteria for the requested 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 Vertiflex Superion device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supartz FX 25 mg/2.5 ML injections. 
 
You asked the Plan to pre-approve supartz injection. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that supartz injections are only covered for certain 
indications. 
 
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 supartz injection. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has bilateral knee osteoarthritis. The LCD states that 
viscosupplementation will not be covered when a repeat series of injections is initiated prior to six months after 
completion of the previous course of treatment. Six months have not passed since the enrollee last received 
treatment. Therefore, the enrollee does not meet criteria for the requested 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 supartz injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve supartz FX 25 mg/2.5 ML injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic parenteral drugs, two or more 
administrations, different medications (D9612) and the bone replacement graft for ridge preservation (D7953). 
 
 
You asked the Plan to pre-approve the parenteral drugs and bone replacement graft for ridge preservation. You 
say that the requested services are necessary. The Plan denied your request. The Plan says the requested 
services are not covered under your supplemental 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. 
 
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 the 
therapeutic parenteral drugs, two or more administrations, different medications (D9612) and the bone 
replacement graft for ridge preservation (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 25, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. 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 physician's services provided on September 25, 2020.