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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, or home with home health services. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
osteomyelitis and had a below the knee amputation. Medical conditions are stable. There are no medical needs 
requiring inpatient admission. 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. 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 you 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 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 pontic (D6240) and two retainer crowns (D6750 x2). 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that these services are medically 
necessary. The Plan denied your request. The Plan says these services are not covered under your dental 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 
pontic (D6240) and two retainer crowns (D6750 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on May 1, 2019, to May 14, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you just wanted to be 
healthy. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $360 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $360 copayment per day for days 1-5. There is a $0 copayment for additional 
days for an inpatient hospital stay. The total amount you are being asked to pay is $1,800 ($360 x 5 days = 
$1,800). An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay provided by a participating provider on 
May 1, 2019, to May 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 22. 
 
You asked the Plan to pre-approve the dental service. You say that the core build up is necessary. The Plan 
denied your request. The Plan says core build up is not listed as a covered service. 
 
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. The Customer Handbook clearly states if a dental item or service is not 
listed in the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan does not 
have to pre-approve core build up (D2950) for tooth # 22.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on August 10, 
2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you had no choice but to get the 
comprehensive exam with the new provider, because it is required for all new patients. The Plan denied your 
request. The Plan says benefits for this service have been satisfied and the frequency limitation has been 
exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation is 
limited to one procedure every three years. The record shows that you received a comprehensive oral 
evaluation on March 28, 2019, and your comprehensive oral evaluation benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on August 10, 
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 21, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 21, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 21, 
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22869). 
 
You asked the Plan to pre-approve Insertion of Interlaminar/Interspinous Process Stabilization/Distraction 
Device (22869). You say that this procedure is the most appropriate treatment for the enrollee. The Plan denied 
your request. The Plan says the clinical value and effectiveness of the Vertiflex Superion Interspinous device 
have not been demonstrated in peer-reviewed literature. 
 
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 Insertion of Interlaminar/Interspinous 
Process Stabilization/Distraction Device (22869). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the device is 
experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device 
(22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve Insertion of 
Interlaminar/Interspinous Process Stabilization/Distraction Device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not indicate a trial with the basic device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided, there is no documentation that the enrollee has unique 
characteristics that would indicate the segmented pump over a standard pump as there has been no documented 
failure of four weeks of use of the standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a segmented pneumatic compression device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cone beam CT, both jaws (D0367). 
 
You asked the Plan to pre-approve the dental service. You say that a plan representative informed you that the 
procedure would be covered before you changed to this plan. You also say that you feel you were misled by the 
plan representative. The Plan denied your request. The Plan says cone beam CT, both jaws, is not listed as a 
covered service. 
 
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 
cone beam CT, both jaws (D0367).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for surgical services provided from June 15, 
2020, to August 24, 2020. 
 
You asked the Plan to waive the copayments for outpatient surgical services. You say that you are appealing 
these claims. The Plan denied your request. The Plan says the copayment amounts you are being charged are 
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 $345 
copayment for in-network surgery services provided at an outpatient hospital. For each date of service, you 
have been asked to pay the allowed amount of $243.19, because this is less than the $345 outpatient surgery 
copayment. There were 3 visits, resulting in a total copayment amount of $729.57. 
 
You have been asked to pay less than $345 copayment for outpatient surgical services. Outpatient surgical 
services fall 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 copayments for surgical 
services provided from June 15, 2020, to August 24, 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 was undergoing treatment at an ACH for osteomyelitis. The enrollee was not 
intubated/ventilated. There is no evidence that the enrollee required services that were not currently available. 
As LTACHs and ACHs are licensed to provide the same level of care, there was no advantage in transferring 
the enrollee to the LTACH. The enrollee could remain at the ACH until such time no acute services were 
required. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee urgently needs care in an IRF. The Plan 
denied your request. The Plan says the guidelines for coverage of IRF care have not been met. 
 
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 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 treatment of a perforated colon. The enrollee's medical conditions are 
stable. There are no medical needs requiring inpatient admission. 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 
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 the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 92 miles of routine transportation (A0170) 
per one-way trip. 
 
You asked the Plan to pre-approve the additional mileage. You say that the transportation is necessary as you 
have been referred to a specialist for your condition. The Plan denied your request. The Plan says this service is 
a covered benefit; however, your request exceeds the benefit limit. 
 
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.  
 
We looked at your request, the records in the case file, and the Plan's rules. Based on this information, we 
decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the Plan 
provides coverage for 50 miles for each one-way trip. You have requested transportation to a destination that is 
142 miles from your home. Your request exceeds the benefit limit. Therefore, we decided that the Plan does not 
have to pre-approve an additional 92 miles of routine transportation (A0170) per one-way trip.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10mg Rosuvastatin tablets. 
 
You asked the Plan to pre-approve the Rosuvastatin. You say that you would like reconsideration because the 
member is intolerant of atorvastatin and there is an interaction between simvastatin and amlodipine. The Plan 
denied your request. The Plan says this medication does not fall under Part B. 
 
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 10mg Rosuvastatin tablets.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services provided on August 31, 2020. 
 
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says you last 
received the eyewear benefit for eyewear provided on September 17, 2018. You would have been eligible for 
the eyewear benefit on September 17, 2020. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services every two years. 
 
We looked at the file and the Plan's rules. The file shows that the eyewear benefit is provided every two years 
and the benefit was exhausted on September 17, 2018.  Based on this information, we decided that the Plan's 
rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have 
to pay for vision services provided on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the root canal 
(D3330) provided on August 26, 2020. 
 
You asked the Plan to pay for the dental services. You say that your booklet that you got in 2019 when you 
signed up for the plan shows that 2 crowns and 1 root canal are covered. You say that your 2020 Annual Notice 
of Changes only showed that the premium was changing, nothing else. The Plan denied your request. The Plan 
says the provider in this case is out of network. The Plan says that there is a 50% coinsurance when you receive 
a limited oral evaluation (emergency exam) out of network. The Plan says you may be billed by the out of 
network provider for any amount greater than the payment made by the Plan to the provider. The Plan also says 
that the root canal is not listed as a covered service. 
 
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, there is a 50% coinsurance for the 
emergency exam that you received out of network. This is a contractual obligation you agreed to when you 
enrolled in the Plan's dental coverage. The Evidence of Coverage states you may be billed by the out of 
network provider for any amount greater than the payment made by the Plan to the provider. Additionally, the 
root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140) and the root canal (D3330) provided on August 26, 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 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 surgical treatment of intracranial AVM. Medical conditions are stable. There are no 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.