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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is 
mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer 
duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An 
IRF intensity is not warranted. 
 
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 powered elbow orthotic. 
 
You asked the Plan to pre-approve a powered elbow orthotic. You say that this is medically necessary for you. 
The Plan denied your request. The Plan says that this is considered experimental, investigational or unproven 
and is therefore not covered by the plan. 
 
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 a powered elbow orthotic. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. There 
are no long term studies demonstrating the safety and efficacy of these devices. The orthotic is considered 
experimental, investigational or unproven at this time. Our physician reviewer found that your condition does 
not meet Medicare criteria for coverage of this item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a powered elbow orthotic have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a powered elbow orthotic.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, skin care, and daily therapy can be provided at a SNF. In this case, you are mostly 
minimal assist for functional transfers and activities of daily living (ADL?s) and a less intensive, longer 
duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An 
IRF intensity is not warranted. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a hallux valgus correction (28292) provided on September
27, 2019.
You asked the Plan to pay for the hallux valgus correction. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the service billed.
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 28292 is correction, hallux valgus (bunionectomy), with
sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method to
the health plan for reimbursement consideration. The health plan denied payment for 28292 LT stating the
medical records do not support billing the code.
We asked our coder 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 hallux valgus correction. Our reviewer says that CPT
code 28292 does not meet criteria for billing or reimbursement consideration. Our reviewer found The medical
records provided do not include documentation to corroborated that a Correction, hallux valgus
(bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when
performed, any method was performed on the billed date of service.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the hallux valgus correction have not been met. Therefore, we decided that the
Plan does not have to pay for a hallux valgus correction (28292) provided on September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prosthesis from an out-of-network provider.
You asked the Plan to pre-approve a replacement prosthesis from an out-of-network provider. You say that you want to go to the out-of-network provider for services. The Plan denied your request. The Plan says a replacement prosthetic leg socket and services are available in-network.
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 a replacement prosthesis from an out-of-network provider.
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 because of medical issues the enrollee 
needs incontinence 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you have undergone treatment at the facility 
in the past and prefer to go there. The Plan denied your request. The Plan says necessary services may be 
obtained in-network. 
 
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 
physical therapy to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient drug rehabilitation for the enrollee. 
 
You asked the Plan to pre-approve inpatient drug rehabilitation. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the member's treatment can safely take place at a 
lower intensity than residential level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient drug rehabilitation. Our 
reviewer says that inpatient drug rehabilitation not considered medically reasonable and necessary in this case. 
Based upon review the records provided in cases such as this an evidence-based, objective, instrument such as 
the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in 
determining necessary level of care for adults. In terms of risk of harm, the records support a score of 1 due to a 
lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records 
support a score of 1 due to minimal impairment in function. In terms of medical, addictive and psychiatric 
comorbidity, the records support a score of 1 no significant medical comorbidity. In terms of level of stress of 
the recovery environment, the records support a score of 1 due to a stable living situation. With regards to level 
of support for the recovery environment, the records support a score of 1 due support as being court ordered. 
With regards to treatment and recovery history, the records support a score of 1 due to fully responsive to 
treatment and recovery management. In terms of engagement and recovery status, the records support a score 
of 1 due to cooperation in treatment and insight into his need for treatment along with insight into her treatment 
needs. Thus, the patient has a composite score of 7. This correlates with treatment in a community-based 
outpatient clinic setting. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of inpatient drug rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient drug rehabilitation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient drug rehabilitation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve medical supplies to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the medical supplies from an OON provider. You say that the closest 
participating provider is 100 miles round trip from your home. The Plan denied your request. The Plan says 
there are in network providers who can supply the items being requested, including in network providers who 
can mail the items you are seeking directly to your home. 
 
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 
medical supplies to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks.
You asked the Plan to pre-approve the genicular nerve blocks. You say that you would like reconsideration because this service is medically necessary. 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. 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 genicular nerve blocks. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. 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 genicular nerve blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve blocks.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services. 
 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee fell off of her bike and that an MRI is 
needed for an orthopedic appointment and for possible surgical pre-planning. The Plan denied your request. 
The Plan says the information sent does not show a medical need for the requested MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically necessary. Our physician reviewer found there is no documentation of adequate 
conservative measures for knee pain to include recent physical therapy. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup.
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says the 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 the
core buildup.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you were charged for a 
maxillary partial denture and mandibular partial denture on September 10, 2019 that you never received. The 
Plan denied your request. The Plan says partial dentures are a benefit once every 5 years. The Plan also says 
that this dentures benefit has been exhausted. 
 
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, partial dentures are limited to one 
upper and/or one lower partial denture every five years. The record shows that you received a mandibular 
partial denture on September 10, 2019 and your mandibular partial denture benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee walker. 
 
You asked the Plan to pre-approve a knee walker. You say that after your surgery you will need a knee scooter. 
The Plan denied your request. The Plan says a knee walker is not a covered benefit under your Medicare 
benefit plan. 
 
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. Knee scooters are statutorily excluded by Medicare. Therefore, we 
decided that the Plan does not have to pre-approve a knee walker.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 26 to 
October 29, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this admission was the result of a premature discharge 
from an earlier admission. 
 
The Plan must follow Medicare rules. The rules say that readmission review involves admissions to an acute, 
general, short-term hospital occurring less than 31 calendar days from the date of discharge. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the readmission was for the same x-ray findings in a stable patient with no new 
respiratory symptoms. The admission was 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 26 to October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee requires this treatment. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would like to see this doctor because you know someone who had success with them. 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 specialist services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transit Package (K0108).
You asked the Plan to pre-approve the Transit Package. You say that you would like reconsideration because this supply is medically necessary. The Plan denied your request. The Plan says the item in question is not an integral part of the wheelchair base.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a Transit Package (K0108).