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

We decided that the Plan does not have to pre-approve LTACH services for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. 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 she is currently receiving care. It 
is not clear that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve CardioMEMS. 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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee a diagnosis of Chronic systolic (congestive) heart failure, as well as coronary artery 
disease, hypertension, atrial fibrillation, and sleep apnea. The enrollee was hospitalized in July, 2020 with atrial 
fibrillation with rapid ventricular response and congestive heart failure. The efficacy of the CardioMEMS heart 
failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and 
safety of this device. 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS.
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 you are rapidly declining physically and need care, 
attention and consistency that an inpatient rehab facility can provide. The Plan denied your request. The Plan 
says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You have a past medical history of atrial fibrillation, 
diabetes, multiple myeloma, diabetes, seizures and hypertension and are living at home with complaints of 
frequent falls. Your 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. 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 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: 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 the enrollee needs continued cardiac 
monitoring and wound care. The Plan denied your request. The Plan says the enrollee's care can be provided at 
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 physician 
reviewer found that the enrollee was admitted to the hospital with third degree burns and frostbite. Th enrollee 
is receiving appropriate care at the present acute care facility. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where he 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. 
 
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 a consultation with an oral surgeon (D9310). 
 
You asked the Plan to pre-approve a consultation with an oral surgeon. You say that this is medically 
necessary. The Plan denied your request. The Plan says services performed by an oral surgeon are not covered. 
 
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, it only covers services performed by a 
participating general dentist.  Therefore, we decided that the Plan does not have to pre-approve a consultation 
with an oral surgeon (D9310).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that once the enrollee completes the course of care at the inpatient rehab 
facility, the services she will require are custodial care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) abdomen and pelvis (74176) 
provided May 18, 2020. 
 
You asked the Plan to pay for the CT scan. You say that you are sending report for reconsideration. Please 
review and reprocess for payment. Per medical records place of service is correct. The Plan denied your 
request. The Plan says the claim was billed with an inappropriate place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 74176 is computed tomography, abdomen and pelvis.  
 
We find that CPT code 74176 is not supported in the medical record. Specifically, the place of service billed 
doesn't match other claims for the same date of service. According to claims history, the enrollee was inpatient 
during this date of service. Based on this information, we decided that Medicare rules for coverage of the CT 
scan have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography 
(CT) abdomen and pelvis (74176) provided May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for anti-reflective (V2750), progressive (V2781) and high index 
(V2783) lens upgrades provided on December 14, 2020. 
 
You asked the Plan to pay for the lens upgrades. You say that you did not know that lens upgrades were not 
covered. The Plan denied your request. The Plan says lens upgrades are not covered by the Plan's vision 
benefit. 
 
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 one pair of eyewear with lenses (single vision, bifocal, or trifocal), standard frames, 
or eyeglasses (both lenses and frames) every 24 months. Vision services and/or materials that are primarily for 
cosmetic purposes, such as lens upgrades, are not covered by the Plan. 
 
We looked at the file and the Plan's rules. In this case, the contract clearly indicates that lens upgrades are not 
covered by this Plan. Therefore, we decided that the Plan does not have to pay for anti-reflective (V2750), 
progressive (V2781) and high index (V2783) lens upgrades provided on December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve L5986. We decided that the Plan does not have to pre-approve 
L5981.  
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan says that a 
request for a K3 foot does not meet the Medicare criteria as reasonable and necessary. 
 
We decided that the Plan has to pre-approve L5986.  
 
The Plan follows Medicare rules. The rules say that an axial rotation unit (L5986) is covered for beneficiaries 
whose functional level is 2 or 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 for the axial rotation unit (L5986). Our reviewer says 
that this accessory is medically necessary. Our physician reviewer found that an axial rotation unit (L5986) is 
covered for beneficiaries whose functional level is 2 or above. The documentation supports that the enrollee's 
functional level 2 or above. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5986 have been met. Therefore, we decided that the Plan has to pre-approve 
L5986.  
 
We also decided that the Plan does not have to pre-approve L5981. 
 
The Plan follows Medicare rules. The rules say that a flex-walk system or equal (L5981) is covered for 
beneficiaries whose functional level is 3 or 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 for the flex-walk system or equal (L5981). Our 
reviewer says this is not medically reasonable or necessary. Our physician reviewer found that a flex-walk 
system or equal (L5981) is covered for beneficiaries whose functional level is 3 or above. The documentation 
does not support that the enrollee is currently a functional level 3 or above. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5981 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve L5981. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the neck for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered and not medically necessary. 
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the case file indicates 
that a CT angiogram of the head has been approved but that a CT neck CPT 70492 has also been requested. A 
CT neck CPT 70492 is not a medically reasonable and necessary study to evaluate carotid artery disease. The 
available documentation does not indicate any other reason for the requested study. The requested study cannot 
be recommended. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the neck for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation service (A0425, A0427) 
provided on September 18, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the member was enrolled in the Federal 
hospice program on this date of service. Therefore, original Medicare is responsible for payment of this service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance transportation service (A0425, A0427) 
provided on September 18, 2020.
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 you need an inpatient rehabilitation facility 
admission. The Plan denied your request. The Plan says IRF services are 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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested routine eye exam. 
 
You asked the Plan to pre-approve the routine eye exam. The Plan denied your request. The Plan says you have 
exceeded the limit of one routine eye exam every twelve months. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
one routine eye exam every twelve months from a Plan vision provider. 
 
We looked at the file and the Plan's rules. The file shows that the Plan paid for a routine eye exam on 
June 29, 2020.  Based on this information, we decided that the Plan's rules for coverage of the routine eye exam 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the requested routine eye 
exam.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal (D6240) 
and retainer crown - porcelain fused to high noble metal (D6750). 
 
You asked the Plan to pre-approve pontic and retainer crown.. You say that these services are necessary. The 
Plan denied your request. The Plan says these 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 
pontic - porcelain fused to high noble metal (D6240) and retainer crown - porcelain fused to high noble metal 
(D6750).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on November 2, 
2020. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that you have not been charged for 
this procedure in the past. 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 $130 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a freestanding facility (such as a radiology center or medical clinic).  
 
You have been asked to pay a $130 copayment for the duplex scan. The duplex scan falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" 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 duplex scan provided on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D1999, D0220, D0230) provided November 
12, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage rules have not been met. 
 
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, CPT code D1999 is not listed as a 
covered benefit. Intraoral x-rays (D0220, D0230) are covered once a year and the record shows this service was 
already covered once previously. The benefit was exhausted at the time services were performed. Therefore, we 
decided that the Plan does not have to pay for dental services (D1999, D0220, D0230) provided November 12, 
2020.