Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for you to receive IRF care. 
The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met and the 
enrollee's needs can be met at a skilled nursing facility (SNF). 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. At the current functional level, the enrollee does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. 
 
The documentation does not support necessity for admission to an IRF due to lack of medical complexity, and 
lack of rehab nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, 
the enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in an SNF 
or in-home with services and family support. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year 
and older than 70 (CPT code 99100) provided on February 24, 2022. 
 
You asked the Plan to pay for the service. You say that the service is separately payable. The Plan denied your 
request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year and older than 70 (CPT code 99100) provided on 
February 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. Your providers have not been happy with the level of care 
provided at the hospital. The Plan denied your request. The Plan says that the 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 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 you are at a functional level and a deconditioned state following an acute illness 
which does not require intensive rehabilitation to restore or maintain function. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm-brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro powered arm-brace. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested item is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro powered arm-brace. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current clinical guidelines designate robotic therapy to be of "uncertain utility 
compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home 
environment. In addition, provided records report right upper extremity spasticity, which may be a 
contraindication to use of the requested 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 a MyoPro powered arm-brace have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a MyoPro powered arm-brace (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this device is medically 
necessary for your condition. The Plan denied your request. The Plan says the requested device is considered 
experimental/investigational. 
 
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 MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the requested device is not medically necessary. The requested 
MyoPro device is not the standard of care for your condition. You have no difficulties caring for yourself, 
dressing, bathing, or walking. There is no left elbow exam or deficits on an objective physical exam of elbow 
dysfunction supporting the need for this 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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain/ceramic crown on teeth numbers 4, 5, and 29. 
 
You asked the Plan to pre-approve a porcelain/ceramic crown on teeth numbers 4, 5, and 29. You say that full 
coverage crowns will be needed for a favorable prognosis on teeth numbers 4 and 5. You also say that tooth 
number 29 has very deep mesial occlusal distal buccal (MODB) carries present. The Plan denied your request. 
The Plan says that the information provided does not meet the criteria for approval for a crown under this plan. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to provide any medical records. The medical records are needed 
to review and process this case. The decision letter sent by the Plan even verifies that they received the medical 
records to process their appeal. However, the Plan did not forward them for the consideration of this appeal. 
Therefore, we decided that the Plan has to pre-approve a porcelain/ceramic crown on teeth numbers 4, 5, and 
29.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigationper quadrant (D4921 x 4) provided on 
June 14, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigationper quadrant (D4921 x 4) provided on June 14, 2022.
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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 you do not require services at the LTACH that are not available at the acute care 
hospital or the skilled nursing facility. The requested treatments are not medically necessary at the LTACH 
level of care. You have improved medically and can receive further care at the current acute care hospital or a 
lower level of care when deemed appropriate.  
 
   
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, of an erupted tooth requiring removal of bone
and/or sectioning of tooth (D7210) provided on May 13, 2022.

You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the
Plan's denial for payment. The Plan denied your request. The Plan says this service is not covered under your
contractual policy.

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 service provided is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, of
an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on May 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
October 20, 2022. 
 
You asked the Plan to pre-approve SNF care after October 20, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF 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 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 after October 20, 2022. Our 
reviewer says that the continued SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found continued daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical 
matter, can be provided 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 SNF care after October 20, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after October 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a maxillary partial denture on April 20, 
2022. 
 
You asked the Plan to waive the copayment for a maxillary partial denture. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged 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 $450 
copayment for a maxillary partial denture.  
 
You have been asked to pay a $450 copayment for a maxillary partial denture. This item/service falls within the 
dental services 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 a maxillary partial denture 
on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns on tooth #7, 8, 9, and 10 (D2740). 
 
You asked the Plan to pre-approve crowns. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the requested crowns are not medically necessary. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide diagnostic quality radiographs for the determination of 
coronal breakdown or periodontal support. The Plan did not support their decision to deny your request. 
Therefore, we decided that the Plan has to pre-approve crowns on tooth #7, 8, 9, and 10 (D2740).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex interspinous spacer device. 
 
You asked the Plan to pre-approve Coflex procedure. You say that you are in a lot of pain. The Plan denied 
your request. The Plan says studies have not proven that this is helpful. 
 
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 Coflex procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Coflex device is experimental. More research is needed to show the safety and 
efficacy of this 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 Coflex procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Coflex interspinous spacer device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mic-Key gastrostomy tube supplies using current 
procedural terminology (CPT) code B9998. 
 
You asked the Plan to pre-approve gastrostomy tube. You say that you are appealing this denial. The Plan 
denied your request. The Plan says there is a more appropriate code to use for this supply, which is B4088. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code B9998 is enteral supplies, not otherwise specified. 
 
We find that CPT code B9998 is not appropriate for this request. Specifically, code B4088 is a more 
appropriate code to describe the requested gastrostomy tube. Please contact the Plan for more information 
about correcting the coding for the requested supplies. Based on this information, we decided that Medicare 
rules for coverage of gastrostomy tube have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Mic-Key gastrostomy tube supplies using current procedural terminology (CPT) code B9998.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in the presence of generalized moderate or severe 
gingival inflammation (D4346) provided on May 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know this service was not covered. 
The Plan denied your request. The Plan says scaling in the presence of generalized moderate or severe gingival 
inflammation (D4346) is not covered by 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. Therefore, we decided that the Plan does not have to pay for scaling in 
the presence of generalized moderate or severe gingival inflammation (D4346) provided on May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that you desperately need the scooter to make it easier to 
get around and be able to attend your medical appointments.  The Plan denied your request. The Plan says they 
do not have evidence that it is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 
 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 scooter. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you have a personal mobility deficit that 
impairs participation in MRADLs. Your mobility deficit is helped by a manual wheelchair and rollator for 
community distances. The documentation does not support that the requested POV will significantly improve 
MRADL performance in the home. You have a PCA for ADLS and IADLs. The home is not accessible to get 
the POV in and out of the home. The criteria for the power operated vehicle have not been met. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power operated vehicle (POV) (K0800).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve biological materials to aid in soft and osseous tissue regeneration 
on tooth #7, 8, 9, 15, 21, 28, and 29 (D4265). 
 
You asked the Plan to pre-approve biological materials. You say that the provider wants to do the services to 
work on your nasal passages and the gums are covering the tooth. The Plan denied your request. The Plan says 
that the requested teeth have already been extracted. 
 
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 Plan covers biological 
materials when the services are medically necessary and reasonable. 
 
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 biological materials. Our reviewer says 
that the coverage criteria has been met. Our physician reviewer found that the purpose of the placement of this 
material is to preserve bone height and width after an extraction and provide ridge support for a prosthesis.  
The service, D4265, for tooth #7, 8, 9, 15, 21, 28, and 29 which have been approved for extractions, meets the 
criteria for coverage of medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of biological materials have been met. Therefore, we decided that the Plan has to 
pre-approve biological materials to aid in soft and osseous tissue regeneration on tooth #7, 8, 9, 15, 21, 28, and 
29 (D4265).  
 
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.