Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee made more progress in physical 
therapy sessions. The Plan denied your request. The Plan says the enrollee does not require skilled assessment 
from a qualified medical professional. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our physician 
reviewer found that the enrollee can complete bed mobility without assist, can use the restroom and self-care 
independently, requires only supervision for ambulation with a walker, and is independent with a walker to 
restroom. The requested additional therapy is not generally accepted as specific and effective therapy for the 
enrollees condition. The enrollee has had extensive therapy for this condition, and it does not appear that his 
functional level requires the ongoing unique skills of a professional therapist to safely and effectively provide 
treatment, or that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. He has been instructed and compliant in an independent exercise program. 
Therefore, the specialized skill, knowledge and judgment of a qualified therapist is not required to establish or 
design a program to maintain the enrollees current condition, or to prevent or slow further deterioration. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 60 one-way transportation 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 (A0120).
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the available therapy notes do not provide evidence that the patient 
would be able to participate in and tolerate 3 hours of therapy 5 days per week. 
 
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. 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 coronary artery 
bypass grafting. Surgery was complicated by cerebrovascular accident. Medical problems are stable. There are 
no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. 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. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy (J9228). 
 
You asked the Plan to pre-approve Yervoy. You say that the medication is 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Yervoy. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the requested use is not FDA approved or 
supported in any of the CMS approved compendia. Therefore the requested use is not medically reasonable and 
necessary or safe and effective for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Yervoy (J9228).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the records show the enrollee does not require daily skilled therapy to 
care for himself. 
 
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 skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device for the shoulder. 
 
You asked the Plan to pre-approve continuous passive motion device. You say that you need this device 
because of a shoulder problem. The Plan denied your request. The Plan says the denial of authorization for this 
item is correct, because this item is used for comfort and convenience and is not covered. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion device for the shoulder.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full mouth debridement (D4355). 
 
You asked the Plan to pre-approve full mouth debridement (D4355). You say that the service was never 
performed by the first dental office. You say that you should be able to get the cleaning and not have to wait. 
The Plan denied your request. The Plan says full mouth debridement cannot be performed less than one 
calendar year after an evaluation. 
 
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, you cannot receive full mouth 
debridement less than one calendar year after an evaluation. The Plan paid for a comprehensive oral evaluation 
(D0150) provided on August 4, 2020, which exhausted your benefit. Therefore, we decided that the Plan does 
not have to pre-approve full mouth debridement (D4355).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says this request 
exceeds the benefit limit. 
 
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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the requested additional trips will exceed the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve 10 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct, because you do not meet the 
Medicare criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections, medial branch blocks, and facet 
joint radiofrequency neurotomy are only covered under certain clinical indications. 
 
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 facet joint injections. Our reviewer says 
that you do not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found 
the documentation submitted does not include recent imaging studies. There is no documentation of recent 
conservative care. You previously had radiofrequency ablations on 2 occasions with 90% improvement in pain 
but the prescriber did not clarify which of these procedures provided 90% improvement nor how long this 
improvement lasted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
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 the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria has 
not been met. 
 
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: 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 you are in pain from a past surgery. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve back surgery. 
 
You asked the Plan to pre-approve back surgery. You say that you have been dealing with this pain for over a 
year. You are asking for reconsideration for the surgery as you are hopeful that will be a more permanent 
repair. The Plan denied your request. The Plan says the request for back surgery is not medically necessary at 
this time. The plan has referred the enrollee to the Spine Clinic or Neurosurgery for an evaluation. 
 
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 back surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the decision for a surgical intervention requires a surgical consultation first.  Absent a consult, 
any intervention is deemed 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 back surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve back surgery.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 48 one-way transportation 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 (A0120).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional skilled nursing visits. 
 
You asked the Plan to pre-approve 3 skilled nursing visits. You say that the skilled nursing visits are medically 
necessary. The Plan denied your request. The Plan says the rules for additional home health skilled nursing 
visits have 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 3 skilled nursing visits. Our reviewer 
says that enrollee does not require ongoing home health nursing services. Our physician reviewer found the 
enrollee does not have documented skilled nursing needs. The enrollee does not meet Medicare criteria for 
coverage of the 3 additional home health skilled nursing visits. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 skilled nursing visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 3 additional skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 10. 
 
You asked the Plan to pre-approve the dental service. You say that the provider sent a pre-authorization for a 
crowns and root canal treatments for teeth # 10 and 11. You say that you need both treatments approved or with 
discounts. You also say that you cannot pay for this due to your financial status. The Plan denied your request. 
The Plan says core build up is not listed as a covered service. 
 
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 core 
build up (D2950) for tooth # 10.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation trips. You say that you need transportation to 
appointments. 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 six (6) 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 routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power operated vehicle. 
 
 
 
You asked the Plan to pre-approve the power mobility device. You say that you would like reconsideration 
because you are in pain and have trouble walking. The Plan denied your request. The Plan says a walker with a 
seat would be more appropriate for you. 
 
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 power mobility device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation that you have a mobility limitation that 
significantly impairs his ability to participate in one or more mobility-related activities of daily living such as 
toileting, feeding, dressing, grooming, or bathing in customary locations in the home. 
 
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 power mobility device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 1 power operated vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient discharge management services provided on 
March 6, 2020. 
 
You asked the Plan to pay for the discharge services. You say that this should be paid since when a patient is 
admitted and discharged on a different calendar date, the discharge code shall be reported. The Plan denied 
your request. The Plan says this cannot be paid on the same date as an initial hospital care service. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made for discharge services if the 
enrollee is discharged the same date as he/she was admitted. 
 
In this case, the billing provider reported and was paid for initial hospital care services provided on March 6, 
2020 via code 99223, meaning this was the date the enrollee was admitted to inpatient status. If the enrollee 
was discharged less than 8 hours later, no discharge code should be reported. If more than 8 hours passed 
before discharge, then the initial hospital code should not be billed and a code from the 99234-99236 range 
would be reported for the entirety of the services provided on that date. In no case can 99223 and 99239 be 
reported on the same date of service. Therefore, we decided that the Plan does not have to pay for the inpatient 
discharge management services provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital clinic services you 
received from May 4, 2020, through May 28, 2020. 
 
You asked the Plan to waive the copayment for the outpatient hospital clinic services. You say that this cost 
sharing is outrageous. The Plan denied your request. The Plan says you were charged these copayments 
correctly. 
 
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 $325 
copayment for non-surgical visits in an outpatient hospital clinic.  
 
You have been asked to pay a $325 copayment for the outpatient hospital clinic services. 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 outpatient hospital clinic services you received from May 4, 2020, 
through May 28, 2020.