Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Fluciclovine f-18 (A9588x10) provided on September 19, 
2019. 
 
You asked the Plan to pay for the Fluciclovine f-18. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation does not support the units 
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. 
 
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 Fluciclovine f-18. Our reviewer says that 10 units of CPT 
code A9588 does not meet criteria for billing or reimbursement consideration. Our reviewer found the 
procedure report does not document that 10 millicurie was given to support units billed. 
 
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 Fluciclovine f-18 have not been met. Therefore, we decided that the Plan 
does not have to pay for Fluciclovine f-18 (A9588x10) provided on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3320) and periodontal scaling and 
root planing (D4341). 
 
You asked the Plan to pre-approve endodontic therapy and periodontal scaling and root planing. The Plan 
denied your request. The Plan says the enrollee's benefits are 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, there is also a maximum benefit of one 
root canal every year and one periodontal scaling and root planing procedure per quadrant every 3 years. The 
Plan paid for a root canal provided on March 10, 2020, and periodontal scaling and root planing in all 
quadrants on March 6, 2020, which exhausted the benefits. Therefore, we decided that the Plan does not have 
to pre-approve endodontic therapy (D3320) and periodontal scaling and root planing (D4341).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the CT, abdomen; without contrast material, followed by contrast 
material(s) and further sections (CPT Code 74170). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your 
request. The Plan says that the Medicare rules have not been met. 
 
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 CT scan. Our physician reviewer 
found the annual CT scanning is part of post nephrectomy workup and is reasonable and indicated. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve the CT, abdomen; without contrast material, followed by contrast material(s) and further sections 
(CPT Code 74170).  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. 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 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 patient appears to be gradually improving but requires additional short term acute 
care services for less than 25 days for additional stability which can safely be performed at the current facility. 
The patient 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 patient requires that are not already covered and available at the current 
facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power wheelchair and accessories 
(K0801, E2366, E2365). 
 
You asked the Plan to pre-approve the wheelchair. You say that you have experienced several falls. The Plan 
denied your request. The Plan says this type of wheelchair is for members who weight 301-450 pounds. 
 
The Plan must follow Medicare rules. Medicare rules say that a group 1 power wheelchair (K0801) is meant for 
patients between 301 and 450 pounds.  
 
Your weight is 252 pounds, so you do not qualify for this specific wheelchair. Additionally, the accessories 
requested - a lead acid battery and a battery charger - can only be covered if they are for a covered power 
wheelchair. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 heavy duty power 
wheelchair and accessories (K0801, E2366, E2365).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group-3 power wheelchair (K0861). 
 
You asked the Plan to pre-approve the group-3 power wheelchair. You say that you would like reconsideration 
because all codes except that at issue were paid. The Plan denied your request. The Plan says a group-2 Single 
Power Option power wheelchair has essentially the same capability in the home setting as a Group-3. 
 
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 group-3 power wheelchair. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation reveals no objective physical examination from the 
physician in a face to face to indicate the need for the requested chair. The documentation does not reveal that 
the member can safely maneuver the requested device in the rooms as the home evaluation notes small rooms, 
narrow hallways. The documentation does not reveal a trial of the requested power mobility device. 
 
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 group-3 power wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a group-3 power wheelchair (K0861).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) with 
a joint stabilizer (L2385) provided to the enrollee on April 3, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
Therefore the billed code cannot be verified.  The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
knee orthosis with suspension sleeve (L1851, L2397) with a joint stabilizer (L2385) provided to the enrollee on 
April 3, 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires or can fully tolerate 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 inpatient rehabilitation facility (IRF) admission and services.
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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services 
but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation 
therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy 
program provided in an IRF. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses provided on July 14, 2020. 
 
You asked the Plan to pay for the contact lenses. The Plan denied your request. The Plan says you exhausted 
the eyewear benefit on June 4, 2019. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services once every 24 months. 
 
We looked at the file and the Plan's rules. The file shows that you exhausted the eyewear benefit on June 4, 
2019.  Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not 
been met. Therefore, we decided that the Plan does not have to pay for contact lenses provided on July 14, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CPT Code 22869 and 22870. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not  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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer device is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CPT Code 22869 and 22870.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from November 19, 2020, 
forward. 
 
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 at the time of admission, the member required 
skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing 
needs. As of November 18, 2020, the member did not require any skilled nursing or rehab services on a daily 
basis. The member was not expected to make measurable gains within a reasonable and predictable period of 
time or require skilled therapy to prevent deterioration with mobility or ADLs. The member did not require 
skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not 
require any skilled services on an inpatient basis, at a SNF level of care during the period of care under review. 
 
 
The member did not have any parental medications, complex wound care or nutrition given via a feeding tube. 
The member received skilled care and improved, however the member's function had plateaued by November 
18, 2020, and the member did not require any further inpatient skilled rehab services. The member's function 
was at or near their prior level of function and the member could be discharged to a lower level of care for 
further services. During the plan of care under review the member required custodial services. The denial for 
further inpatient skilled care is upheld. 
 
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 continuation of SNF care from November 19, 2020, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be admitted to an IRF for 
medical management and for intense physical rehabilitation. The Plan denied your request. The Plan says the 
records do not show that the enrollee's care is complex. It is unlikely the enrollee could tolerate aggressive 
skilled therapy due to lethargy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for weakness, falls, metabolic encephalopathy and COVID 19-associated pneumonia. Medical 
problems are stable. There are no identified problems that need inpatient medical management. There are no 
complex nursing or rehabilitation needs. The medical record supports a need for physical and occupational 
therapy, but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site 
(D4266), incisional biopsy of oral tissue-hard (bone, tooth) (D7285), collection and application of autologous 
blood concentrate product (D7921) and bone replacement graft for ridge preservation - per site (D7953) 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are necessary. The Plan 
denied your request. The Plan says the services are not a covered benefit under the plan. 
 
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. The services are not listed as a covered benefit; therefore, the services 
are not covered. Therefore, we decided that the Plan does not have to pre-approve guided tissue regeneration - 
resorbable barrier, per site (D4266), incisional biopsy of oral tissue-hard (bone, tooth) (D7285), collection and 
application of autologous blood concentrate product (D7921) and bone replacement graft for ridge preservation 
- per site (D7953)
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided 
from March 1, 2020, to March 29, 2020. 
 
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that you cannot 
pay the copayment. The Plan denied your request. The Plan says you only had $1500 before reaching your out-
of-pocket maximum therefore you were only assessed a $1500 copayment for the services. 
 
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 
copayment of $160 per day for days 21-75 for Skilled Nursing Facility Care.  
 
You have been asked to pay a copayment of $160 per day for days 21-75 for the skilled nursing facility 
services. The skilled nursing facility services falls within the Skilled Nursing Facility Care benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for skilled nursing facility services provided from March 1, 
2020, to March 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 the enrollee is currently receiving care. The 
documentation does not support that an additional 25 days of hospitalization are reasonably expected for the 
enrollee in this case. The requested LTACH services are not medically necessary, reasonable, and appropriate 
for the diagnosis and condition of the enrollee at this time. 
 
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.