Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the services to be provided at the in-network level by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the services. You say that you want to go to providers that specialize in your 
cancer and want the out-of-network services to be provided at the in-network level. The Plan denied your 
request. The Plan says your plan does have out of network benefits you may utilize if desired and there are 
three (3) participating tertiary centers that are available in your network to provide the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 
 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Your plan does have out of network benefits you may utilize if 
desired and there are three (3) participating tertiary centers that are available in your network to provide the 
requested service. Therefore, we decided that the Plan does not have to pre-approve the services to be provided 
at the in-network level by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient home visit with removal of single 
thickened skin growth (99347, 11055) provided on December 13, 2019, by an out of network (OON) provider.  
 
You asked the Plan to pay for the established patient home visit with removal of single thickened skin growth. 
You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. 
The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been 
correctly denied. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the established patient home visit with removal of 
single thickened skin growth (99347, 11055) provided on December 13, 2019, by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a knee roller provided on May 16, 2020. 
 
You asked the Plan to reimburse you for the knee roller. You say that you were unable to use crutches due to a 
fractured ankle and that you received a script for a knee roller from the emergency department. You say that 
you paid out-of-pocket since the equipment was medically necessary in assisting with your mobility. The Plan 
denied your request. The Plan says you received durable medical equipment from a provider who is not under 
contract with the health plan and is not certified for Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The file shows that you purchased the knee roller from an online 
company that is not a provider or a supplier that is enrolled in the Medicare program. Therefore, we decided 
that the Plan does not have to reimburse you for a knee roller provided on May 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve durable medical equipment. You say that this provider has to be a dentist 
and a DME supplier. The Plan denied your request. The Plan says there are in-network providers available for 
these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
durable medical equipment to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need intensive rehabilitation to recover. The 
Plan denied your request. The Plan says the enrollee's needs could be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. While you do require physical therapy and occupational therapy services, you do not require 
an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to weakness and shortness of breath. Care at the skilled nursing facility level appears 
to be more appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and 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 this is medically necessary. The Plan denied 
your request. The Plan says this 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on June 16, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 June 16, 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 June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that you had all the tests you needed within the 
Plan network. You state you want a second opinion to be comfortable knowing what your options are. The Plan 
denied your request. The Plan says there are in-network providers that can render the services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 the enrollee appears to be stabilizing which requires additional short term acute care 
services, which can be safely completed at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Therefore, this request for 
LTACH services will be considered not medically necessary. Transfer may be considered when treatment has 
completed. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction provided from March 18, 2020, to May 
1, 2020. 
 
You asked the Plan to pay for mechanical traction provided in a chiropractic office. You say that all of these 
services should be covered. The Plan denied your request. The Plan says while the Medicare allowed 
chiropractic services were covered, those services not directly related to manual manipulation of the spine are 
not covered in a chiropractic setting. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for mechanical 
traction provided from March 18, 2020, to May 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient care. 
 
You asked the Plan to pre-approve continued inpatient care. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 continued inpatient care. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that you did not have any acute care needs; therefore, you 
were stable for discharge on November 14, 2020 from observation status and didn't meet admission criteria for 
inpatient level of care. You remained stable for discharge from the hospital since that date. The review has 
determined that the items/services at issue in this case were not medically reasonable or 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 continued inpatient care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued inpatient care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve SNF services. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to 
seek out-of-network care. The Plan says there are in-network SNFs available to the enrollee that can provide 
the care being requested. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient's 
fever has resolved. The dermatologist and infectious disease physician signed off. The patient can be followed 
at a lower level of care for lab monitoring and with their hematologist/oncologist. The patient's altered mental 
status, volume overload, tachycardia, and kidney insufficiency are resolved. The patient may benefit from 
multiple therapies such as physical and occupational therapy but the documentation does not support that the 
patient's functional status requires this therapy on an 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and sensors. 
 
You asked the Plan to pre-approve these services. You say that you need to check your blood sugar level six 
times per day. The Plan denied your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered for beneficiaries 
with insulin-treated diabetes. 
 
We looked at the file and Medicare rules. The file shows that you are not on insulin. 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 a Freestyle Libre continuous glucose monitor (CGM) and sensors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two endosteal implants (D6010 x2), inhalation of 
nitrous oxide/analgesia (D9230), and immediate mandibular denture (D5140). 
 
You asked the Plan to pre-approve the endosteal implants, nitrous oxide/analgesia, and immediate mandibular 
denture. You say that you are unable to pay for the non-covered services. The Plan denied your request. The 
Plan says endosteal implant and nitrous oxide/analgesia are not covered benefits. The Plan also says that the 
frequency has been met for the immediate mandibular denture, due to the reline being submitted on the same 
pre-authorization request. 
 
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, endosteal implant and nitrous 
oxide/analgesia are not among those covered under this benefit. The contract says that dentures are limited to 
up to 1 set (either full or partial) every 3 calendar years. The record shows that you were approved for a reline 
of a complete mandibular denture (D5751) on September 23, 2020, and your mandibular denture benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pre-approve two endosteal implants 
(D6010 x2), inhalation of nitrous oxide/analgesia (D9230), and immediate mandibular denture (D5140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670). 
 
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that you need this to monitor 
your blood pressure when you feel dizzy. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that status code "N =Non-covered service." 
 
We looked at the file and Medicare rules. The requested item and its corresponding CPT code, A4670, has a 
status code of N. It is not covered by Medicare. Based on this information, we decided that Medicare rules for 
coverage of an automatic blood pressure monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an automatic blood pressure monitor (A4670).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional psychotherapy visits. 
 
You asked the Plan to pre-approve 10 additional psychotherapy visits. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met. 
 
In order to determine medical necessity that pertains directly to the enrollee and their specific clinical scenario, 
medical records are required. In this case, there was not sufficient medical records provided confirming that the 
10 additional psychotherapy visits are medically necessary. The file shows that the Plan made multiple 
attempts to your provider with no success. Therefore, we decided that the Plan does not have to pre-approve 10 
additional psychotherapy visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that that these services are 
necessary. The Plan denied your request. The Plan says that you have exhausted this benefit. 
 
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. The Plan covers a maximum of twenty (20) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.