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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary, the enrollee 
needs care around the clock. The Plan denied your request. The Plan says the enrollee is unstable for transfer at 
this time. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee's wound care needs are unclear, 
but do not appeal to be complex. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted navigation for total shoulder 
arthroplasty. 
 
You asked the Plan to pre-approve computer-assisted navigation. You say that the enrollee needs this surgery 
as planned. The Plan denied your request. The Plan says studies have not proven that this is helpful with the 
requested surgery. 
 
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 computer-assisted navigation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are no large volume, long-term, high-quality clinical studies that 
confirm the clinical benefits of computer-assisted surgery over standard surgical approaches in total shoulder arthroplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted navigation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve computer-assisted navigation for total shoulder arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781) and addition to lower limb 
prosthesis, vertical shock reducing pylon feature (L5988). 
 
You asked the Plan to pre-approve the vacuum socket system and shock reducing pylon . You say that the 
enrollee meets the definition of medically necessity for the vacuum system and foot components. The Plan 
denied your request. The Plan says the requested vacuum socket and advanced pylon exceeds the enrollee's 
need. 
 
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 prosthesis accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the vacuum-
assisted socket system at issue in this case meets all of Medicare's LCD criteria for medically reasonable and 
necessary for the enrollee. The provided records from the enrollee's treating medical provider do not support 
the vendor's assertion that the vacuum-assisted socket system is medically necessary for the enrollee's 
condition. The vertical shock pylon is not needed since the vacuum system is denied. 
 
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 prosthesis accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve addition to lower limb prosthesis, vacuum pump, residual limb volume 
management and moisture evacuation system (L5781) and addition to lower limb prosthesis, vertical shock 
reducing pylon feature (L5988).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 and L5 kyphoplasties. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says you are outside the time frame for this procedure. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided imaging studies do not corroborate any malignant vertebral fractures at the requested 
surgical levels. The enrollee presented on 2/14/23 with low back pain. The exam reveals a flexion of 90 and 
extension is 20. Strength, sensation, and reflexes are intact. There was no indication of severe pain with pain 
scales noted. The imaging both demonstrated pathology that could be the cause of the noted low back pain. The 
computed tomography (CT) addendum noted retropulsion of both the L1 and L5 vertebral fractures. 
 
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 L1 and L5 kyphoplasties.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for durable medical equipment, code E0730, billed for date of service 
September 7, 2022. 
 
You asked the Plan to pay for the billed services. You say that code E0730 is an accepted procedure code. The 
Plan denied your request. The Plan says that the documentation did not include proof of delivery or medical 
records. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The appeal stats that documentation included the enrollees medical records, a signed prescription, and a 
statement of medical necessity. The Plans case summary confirms that an appeal and medical records were 
provided on November 7, 2022. However, the documentation submitted in the appeal were not included in the 
case file. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for durable 
medical equipment, code E0730, billed for date of service September 7, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and supplies provided on 
July 28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was for use during the enrollee's 
surgery. The Plan denied your request. The Plan says the items were billed for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The claim shows the items at issue were used in an ambulatory surgical center. Although the equipment may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pay for the pneumatic compression device and supplies provided on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-evaluation - post-operative office visit (D0171) provided 
on October 27, 2022. 
 
You asked the Plan to pay for re-evaluation - post-operative office visit (D0171). You say that you are 
requesting the appeal because this service is too expensive and the procedure has been denied. The Plan denied 
your request. The Plan says this service is not covered under the benefit package. 
 
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. Therefore, we decided that the Plan does not have to pay for a re-
evaluation - post-operative office visit (D0171) provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and relining the 
complete maxillary denture (D5750) provided on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial for the dental 
services. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a complete maxillary denture (D5110) and relining the complete maxillary denture (D5750) provided 
on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam (92004), eye refraction (92015), and 
fundus photography (92250) provided on November 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam, eye refraction, and fundus photography. You say that 
these services are covered from an in-network provider. You also say that there was no indication anywhere in 
the Plan's materials that a pre-authorization might have been required. The Plan denied your request. The Plan 
says these services were rendered by an OON provider, and the services were not referred by a network 
provider. The Plan also says that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical eye exam (92004), eye refraction 
(92015), and fundus photography (92250) provided on November 1, 2022, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on October 11, 
2022, by an out-of-network provider. 
 
You asked the Plan to pay for the surgical extraction. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits. 
 
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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the surgical extraction (D7210) provided on October 11, 2022, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary so that you can regain 
your prior level of function and return home pain free. The Plan denied your request. The Plan says the services 
you need can be provided safely in another setting such as a skilled nursing facility, home with home health 
services 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 in the Medicare rules section. 
 
 
 
 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 treatment by multiple therapies. You do not require intensive or 
frequent physiatry oversight.  Your pain and function loss could be managed in an alternate setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 pay for the medical eye exam (92004) and eye refraction (92015) 
provided on October 21, 2022. 
 
You asked the Plan to pay for the medical eye exam and eye refraction. You say that this was your annual eye 
exam which should be fully covered with no copay. You also say that you have received a bill for $79.00 from 
the provider, which you should not have to pay. The Plan denied your request. The Plan says the provider 
billed the eye exam as a Medicare covered medical vision service. The Plan also says that refractions must be 
performed with a routine eye exam to be covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you received a medical eye exam 
for the diagnoses of Age-related nuclear cataract bilateral, Vitreous degeneration bilateral, Puckering of macula 
bilateral, and Myopia bilateral. This was not a routine eye exam. The refraction has to be performed with a 
routine eye exam to be covered. Based on this information, we decided that the Plan's rules for coverage of the 
medical eye exam and eye refraction have not been met. Therefore, we decided that the Plan does not have to 
pay for the medical eye exam (92004) and eye refraction (92015) provided on October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 2, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider told you that the dental services 
would be fully covered. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of August 30, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on September 2, 2022.  
 Your complaint about the provider billing for the services rendered is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are necessary because the enrollee 
needs two therapies and an intensive team. You also say the enrollee is motivated to regain her independence. 
The Plan denied your request. The Plan says the requested IRF services are 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 in the Medicare rules section. 
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an IRF stay. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The member continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status.  
The enrollee can receive further services 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hepatitis A vaccine (90632), and administration (90471) 
provided on October 5, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you initially went to CVS pharmacy to get this 
vaccine. You say that you were advised you would have to pay out-of-pocket. You say that you were advised 
you should go to your doctor's office to not have to pay for this. You also say that your doctor did not advise 
you would have to pay for this. The Plan denied your request. The Plan says the vaccine services are not 
covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the hepatitis A vaccine (90632), and 
administration (90471) provided on October 5, 2022.  
 
Benefits for the vaccine services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that this item is medically necessary. 
The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD.  
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 home mechanical ventilator. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found there is no diagnosis of 
COPD, thoracic restrictive disease, or generalized neuromuscular disease. The Life2000 device is not a true 
ventilator, because it is not capable of providing full ventilatory support. There is inadequate evidence of its 
safety and effectiveness in treating chronic lung disease. 
 
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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).