Persius/hicric huggingface dataset:
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 this patient appears to require additional short-term acute care services as they are 
improving on antibiotics, however, it is unlikely that they will require more than an additional 25 days. The 
patient does not require services at the LTACH that are not already available and covered at the current facility. 
There are no services at the LTACH that the patient requires that are not already available and covered at the 
current facility. Therefore, this request for LTACH services will be considered not medically necessary at this 
time. Transfer to a lower level of care may be considered soon where ongoing IV antibiotics and basic wound 
care can be administered safely. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that it's difficult to shower and you are afraid of 
falling. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary interim partial denture (D5820), four core 
buildups, including any pins when required (D2950 x4), pontic (D6245), and two retainer crowns (D6740 x2). 
 
You asked the Plan to pre-approve the maxillary interim partial denture, core buildups, pontic, and retainer 
crowns. The Plan denied your request. The Plan says these services 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 Plans 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 
maxillary interim partial denture (D5820), four core buildups, including any pins when required (D2950 x4), 
pontic (D6245), and two retainer crowns (D6740 x2).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on January 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this was not 
medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 pay for the services. Our reviewer says that the 
requested ambulance services were medically reasonable and necessary. Our physician reviewer found that the 
enrollee had a specialized need for a heart transplant. The enrollee needed transfer to the facility in question 
due to specialized needs. Given the enrollee's heart transplant status, the requested ambulance transfer was 
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 the services have been met. Therefore, we decided that the Plan has to pay for 
the ambulance services provided on January 10, 2020.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rivastigmine for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered 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 Rivastigmine for the 
enrollee.  
 
Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180), two 
endosteal implants (D6010 x2), and two prefabricated abutments (D6056 x2). 
 
You asked the Plan to pre-approve the comprehensive periodontal evaluation, endosteal implants, and 
prefabricated abutments. The Plan denied your request. The Plan says these services are not covered under the 
enrollee's benefit package. 
 
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 
comprehensive periodontal evaluation (D0180), two endosteal implants (D6010 x2), and two prefabricated 
abutments (D6056 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits for genicular nerve blocks (64450) for knee 
pain. 
 
You asked the Plan to pre-approve the office visits. You say that you receive oral pain medications but do not 
like taking pain medication and would rather just receive the pain management procedure. The Plan denied 
your request. The Plan says there is insufficient published evidence to assess the safety and or impact on health 
outcomes or patient management of genicular nerve blocks for knee pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visits have not been met. Therefore, we decided that the Plan does not have to pre-
approve office visits for genicular nerve blocks (64450) for knee pain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are in need of these supplies. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve ophthalmology consultations to be provided by an out-of-network 
physician. 
 
You asked the Plan to pre-approve consultation visits. You say that the enrollee's function is limited, and it is 
medically necessary for the enrollee to see this provider. The Plan denied your request. The Plan says that the 
denial of authorization for these services is correct, because these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are 
plan providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. You say that the enrollee needs to see this specific ophthalmology physician. 
The Plan has not provided evidence that they have in-network ophthalmology providers available who would 
be able to provide medically necessary care for the enrollees medical condition. The office visits requested are 
Medicare-covered services. Therefore, the Plan has not shown that their decision to deny authorization for out-
of-network ophthalmology consultations is medically correct or justified according to Medicare rules. 
Therefore, we decided that the Plan has to pre-approve ophthalmology consultations to be provided by an out-
of-network physician.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services beginning 
September 16, 2020. 
 
You asked the Plan to pre-approve these services. You say that you need further treatment. The Plan denied 
your request. The Plan says that you can be treated in a lower level of care, such as outpatient treatment. 
 
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 these services. Our reviewer says that 
inpatient psychiatric hospital services are not medically reasonable and necessary in this case. It is not expected 
that you would improve in a reasonable period of time beyond the dates in question as you were not showing 
any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors. You are 
paranoid and delusional but not showing any acute threats of safety. It does 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 you do not have any suicidal or homicidal thoughts, auditory or visual 
hallucinations or abnormal behaviors. Our physician reviewer found that your condition does not meet 
Medicare criteria for inpatient psychiatric hospital 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve inpatient psychiatric hospital services beginning September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 10, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 4, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you say that you did not 
complete your virtual appointment. The Plan denied your request. The Plan says the copayment you are being 
charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each Specialist office visit for Medicare-covered services.  
 
You have been asked to pay a $45 copayment for a specialist visit. Specialist visits fall within the 
physician/practitioner services, including doctor?s office visits, 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 a specialist visit provided on May 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on June 10, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
services at issue. 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 a domiciliary, rest home visit provided on June 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on November 11, 2019 
through December 11, 2019. 
 
You asked the Plan to pay for the mental health services. You say that you would like reconsideration because 
the mental health services were medically necessary and needed on an urgent basis. The Plan denied your 
request. The Plan says you received services from a non-Medicare certified provider and are responsible for the 
entire cost of the services. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
mental health services provided on November 11, 2019 through December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sunglasses frames (S0518) purchased February 21, 2020. 
 
You asked the Plan to pay for the sunglasses frames. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says this item is not covered. 
 
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 1 pair of eyeglasses or contact lenses every 24 months. This claim was billed with an 
S code. S codes are excluded from coverage. 
 
We looked at the file and the Plan's rules. This item is an excluded item and is not covered. Based on this 
information, we decided that the Plan's rules for coverage of the sunglasses frames have not been met. 
Therefore, we decided that the Plan does not have to pay for sunglasses frames (S0518) purchased February 21, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that TTFT is covered for specific indications only. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
metastatic mesothelioma. The records do not document a diagnosis of glioblastoma multiforme (GBM), as 
required by the Medicare rules. The enrollee does not meet the criteria for coverage and the TTFT is therefore 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tumor treatment field therapy (TTFT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat/back cushion for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. The rules say that if the beneficiary has a POV or a power wheelchair 
with a captain's chair seat, the cushion will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. The file shows that the enrollee is approved for a captain's chair seat 
power wheelchair. The requested seat/back cushion is therefore not covered. Therefore, we decided that the 
Plan does not have to pre-approve a seat/back cushion for a power wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing. 
 
You asked the Plan to pre-approve the scaling and planing. You say that the dentist recommended a deep 
cleaning prior to having your cavities worked on. The Plan denied your request. The Plan says this service is 
not 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. 
 
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 
periodontal scaling and root planing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide sensors for use with an interstitial continuous glucose 
monitor (A9276).    
 
You asked the Plan to provide sensors (A9276) for use with an interstitial continuous glucose meter. You say 
that the enrollee needs this type of sensor. The Plan denied your request. The Plan says the enrollee's 
continuous glucose monitor is not one of the Medicare approved monitors so the supplies for it are not 
approved either. 
 
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 A9276 is Sensor; invasive (e.g., subcutaneous), 
disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply.  
 
The sensors are for a non-therapeutic CGM device per Medicare guidelines and is therefore non-covered. 
Based on this information, we decided that Medicare rules for coverage of sensors (A9276) have not been met. 
Therefore, we decided that the Plan does not have to provide sensors for use with an interstitial continuous 
glucose monitor (A9276).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are unable to stand and have no one to 
support or help you shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.