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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system identified with code 
E2300. 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system identified with code E2300.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953). 
 
You asked the Plan to pre-approve the dental service. You say that the requested service is necessary. The Plan 
denied your request. The Plan says bone replacement graft is not listed as a covered service. The Plan also says 
if a dental item or service is not listed in the benefit chart or listed with NC, then it is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Dental Handbook clearly states if a dental item or service is not 
listed in the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan does not 
have to pre-approve a bone replacement graft (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four osseous surgeries and two bone replacement grafts. 
 
You asked the Plan to pre-approve the osseous surgeries and bone replacement grafts. You say that this is a 
dental surgery that you need. The Plan denied your request. The Plan says these services are not covered under 
your dental plan. 
 
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 four 
osseous surgeries and two bone replacement grafts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the enteral nutrition formula (B4149) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve enteral nutrition formula. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is available from in-network providers. 
 
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 enteral nutrition formula (B4149) 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 Dexcom continuous glucose monitor. 
 
You asked the Plan to pre-approve a Dexcom continuous glucose monitor. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is only covered for 
certain indications.  
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee is receiving insulin once 
daily and is only checking blood glucose twice daily. Based on this information, we decided that Medicare 
rules for coverage of a Dexcom continuous glucose monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Logisticare mileage. 
 
You asked the Plan to pre-approve the additional miles. You say that this is medically necessary. The Plan 
denied your request. The Plan says the service is a covered benefit, but the enrollee exceeds limits set in the 
subscriber agreement. 
 
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 routine transportation up to 50 miles one-way.  
 
We looked at your request, the records in the case file, and the rules. You are requesting an excess of 80.3 
miles for this trip. Based on this information, we decided that the Plan's rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
Logisticare mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
 
 
We decided that the Plan does not have to pre-approve power wheelchair accessories (E2300, E1007, E1012) 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for equipment to be covered, it must be for a 
primarily medical purpose. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal why the enrollee is  unable to perform a functional weight 
shift given the medical office visit dated 9/30/20 which indicates upper extremity strength of 4/5 and review of 
systems which is negative for weakness, paralysis, paresthesias, changes in gait, coordination, cramps, myalgia, 
stiffness, joint swelling, backache, skin rashes. The documentation does not reveal use of intermittent 
catheterization or that a powered seating system is needed to manage increased tone or spasticityThe request 
for the E1007 and the E1002 is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Our reviewer found that the powered seating 
system (categorized as E1007 and E1012) are not medically reasonable or necessary. The request for E2300 is 
statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of 
the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve power 
wheelchair accessories (E2300, E1007, E1012)
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continues skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says this care is now custodial in nature and is not covered. 
 
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. Based on the medical records, this care is custodial in 
nature which is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-
approve continues skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services will assist in improving the 
member's current condition. The Plan denied your request. The Plan says that the member reached his baseline 
level of function. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee is noted to be 
confined to the home and under the care of a physician. The enrollee is not shown to be currently in need of 
skilled nursing, physical therapy (PT), speech therapy (ST) or occupational therapy (OT) services. As such, the 
services of a home health aide (HHA) are considered supportive/custodial and are not currently coverable. 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest for the 
enrollee. 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that a CT scan is medically necessary. The 
Plan denied your request. The Plan says Medicare coverage criteria are not 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 a CT scan of the 
chest. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found there is no 
clinical rationale for the requested chest CT. The most recent two office visits in August and October, since 
their hospitalization in June for chest pain indicated that the member has no signs or current symptoms of lung 
disease per history. The enrollee has not had a recent chest X-ray to show any persistent findings since 
hospitalization in June. The review has determined that the requested Chest CT scan is not medically necessary 
or reasonable. 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 CT scan of the chest have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computed tomography (CT) scan of the chest for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for your routine transportation. 
 
You asked the Plan to pre-approve additional miles. You say that you need surgery The Plan denied your 
request. The Plan says your benefit only allows 50 miles. 
 
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 Plans coverage rules apply in this 
case.  
 
Transportation over 50 miles was requested. We looked at your request, the records in the case file, and the 
rules. Your plan only covers transportation for up to 50 miles. Based on this information, we decided that the 
Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional mileage for your routine transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lidoderm 5% patch 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 the Lidoderm 5% patch 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member's current needs are being met in the acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be gradually improving, however, requires additional short term acute care services (less than 25 
days) for oxygen weaning which could be completed at the current facility. The patient does not require 
services at the LTACH that are not already available at the current facility. Our physician reviewer found that 
the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 5 additional extractions (D7250) for teeth # 5, 12, 
13, 15, and 19. 
 
You asked the Plan to pre-approve the 5 additional extractions. You say that you had heart surgery. You say 
that you could not have dental work done for 10 years. You also say that it is in the best interest of your health 
and mental status and would probably die of a stroke if you are not allowed to receive the services. The Plan 
denied your request. The Plan says 6 extractions per year are covered. The Plan says that the frequency limit 
has been reached. 
 
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 and extractions are a covered service, 
the frequency limit of 6 per calendar year has been exceeded. The record shows that the Plan previously 
approved 10 extractions on August 3, 2020. Therefore, we decided that the Plan does not have to pre-approve 
the 5 additional extractions (D7250) for teeth # 5, 12, 13, 15, and 19.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xtandi. 
 
You asked the Plan to pre-approve Xtandi. You say that you need the medication because you are ill. The Plan 
denied your request. The Plan says this medication does not fall 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 Xtandi.  
 
Benefits for Xtandi 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this cannot be accomplished at a lower level of care. 
The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a 
skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy. 
 
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 enrollee is generally medically stable after a hip fracture a with no evidence of 
medical or nursing needs in an IRF. There is no evidence of medical issues that require monitoring by an 
inpatient rehab physician three times a week. The documentation does not support that there is a need for an 
intensive therapy program with 3 hours a day at current level of function and an interdisciplinary approach to 
rehab care. There is no medical complexity for IRF care. The enrollee's rehab needs can be safely and 
effectively met in an alternate, less intense setting such as in an SNF. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 office visits. You say that you have seen this provider for years and do not 
trust any other. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because this provider is out-of-network with the Plan and you can be treated by an in-network 
ophthalmologist. 
 
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.