Persius/hicric huggingface dataset:
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 LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 that the patient is a 65-year-old female who was admitted to the acute care hospital 
with acute respiratory failure and recurrent COVID-19 pneumonia and pulmonary fibrosis complicated by 
Cytomegalovirus infection. She was treated with high flow oxygen and was later weaned to low dose oxygen 
via nasal cannula. However, recent notes describe the patient as worsening and again requiring high flow 
oxygen support without clear weaning potential yet. The patient appears to be currently unstable and requires 
short-term acute care services that can be safely completed at the current facility until more stable and/or more 
appropriate for a lower level of care. The patient does not require services at the LTACH that are not already 
available at the current facility.  There are no services at the LTACH that the patient requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as the patient is not stable and as it would not 
be clinically advantageous. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Medtronic Infuse Bone Graft Allograft. 
 
You asked the Plan to pre-approve the Medtronic Infuse Bone Graft Allograft. You say that this is medically 
necessary for the enrollee's surgery. The Plan denied your request. The Plan says the requested device is 
experimental/investigational for the enrollee's condition. 
 
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 Medtronic Infuse Bone Graft 
Allograft. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found infuse bone allograft remains experimental in the cervical 
spine. It is only approved by the Food and Drug Administration for anterior lumbar surgery. 
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 Medtronic Infuse Bone Graft Allograft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Medtronic Infuse Bone Graft Allograft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), and 
prophylaxis (D1110) provided on December 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that you went to your appointment for a cleaning. 
You say that cleanings are covered twice per year. You also say that you were expecting these services to be 
fully covered. The Plan denied your request. The Plan says the remaining $6.80 of the maximum allowance 
was applied to these services. The Plan says that the remainder of the claim denied for exceeding the $1,000 
annual maximum.  
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 and the services are listed as covered, 
the $1,000 annual maximum has been exhausted. 
 
Date of Service Plan Paid 
3/17/2021 $76 
3/26/2021 $119.20 
4/2/2021 $16.80 
4/2/2021 $109 
4/20/2021 $238.40 
4/30/2021 $246.40 
5/28/2021 $109 
11/30/2021 $78.40 
12/20/2021 $6.80 
TOTAL: $1,000 
 
 
Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation 
(D0180), and prophylaxis (D1110) provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional transportation mileage. The Plan denied your request. The Plan 
says you are requesting an additional 15 miles for a total of 65 miles, and your benefit only allows 50 miles. 
The Plan also says that you have exceeded your 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 Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.   
We looked at your request, the records in the case file, and the rules. You have requested to be transported 65 
miles one way. 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 
transportation mileage (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered arm brace for the enrollee. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are not enough studies to show improved outcomes with this device. 
 
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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found 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. 
Although records from the device manufacturer/vendor argue medical necessity of the requested device, no 
records from the enrollee's actual treating provider clarify why the requested device is the most appropriate 
treatment for the enrollee's condition. In addition, the provided records document the enrollee has upper limb 
spasticity which may be a contraindication to use of the 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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a powered arm brace for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership (S9970) purchased for the 2021 
calendar year. 
 
You asked the Plan to pay for the health club membership. You say that the Plan should reimburse you the full 
cost of this membership. The Plan denied your request. The Plan says you have been reimbursed your full $150 
benefit allowance for these services; you are responsible for the remaining charges. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
up to $150 per calendar year. You pay all charges over $150 per calendar year. 
 
 
 The Plans rules for coverage of gym benefits have not been met because the record shows that the Plan has 
paid the full $150 benefit allowance for the 2021 Plan year. Therefore, we decided that the Plan does not have 
to pay an additional amount for the health club membership (S9970) purchased for the 2021 calendar year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with multiple power options 
including tilt and recline for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pre-approve a power wheelchair with multiple power options including tilt and 
recline for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from April 27, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from April 27, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from April 
27, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of April 27, 2022, forward. Our physician reviewer found you did not 
require inpatient mental health treatment beyond April 27, 2022, as you were not a danger to yourself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from April 27, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from April 27, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant (D6010), bone graft 
(D6104), guided tissue regeneration (D4266), and surgical access to an implant (D6011). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says these are not covered services. 
 
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 pre-approve the 
surgical placement of implant (D6010), bone graft (D6104), guided tissue regeneration (D4266), and surgical 
access to an implant (D6011).
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. The Plan denied your request. The Plan says your continued care 
could be better provided at a lower level of care. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for cervical spine surgery. Your medical problems are stable. 
You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While you 
have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of skilled nursing facility care. 
 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 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee 
does not require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter, 
this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 inpatient skilled nursing facility (SNF) care.
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 you cannot stand for too long and cannot wash 
your lower body when taking a bath. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (code D4381- localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue) you received on December 
16, 2021. 
 
You asked the Plan to pay for code D4381. You say that you do not understand why this service was not 
covered. The Plan denied your request. The Plan says this dental service is not covered under your dental 
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. Your Plan only covers the 
following dental services: oral exams, x-rays, cleanings, emergency oral evaluations, fillings, periodontal 
cleaning, scaling and root planing, full mouth debridement, extractions, and minor pain treatment.  
Though the Plan offers a dental benefit in excess of Medicare coverage, code D4381- localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, is not covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the dental services (code D4381- localized 
delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue) you received on 
December 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test (87635) provided on November 4, 2021. 
 
You asked the Plan to pay for the COVID-19 test. You say that you were in Mexico and were exposed to other 
travelers who had COVID-19. You also say that you think this test should be covered since the government 
required it for re-entry into the country. The Plan denied your request. The Plan says you received a COVID-19 
test while traveling. The Plan also says that per the Plan's COVID-19 guidelines testing is not covered for 
members who need a COVID-19 test to travel. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 test have not been met. The COVID-19 test you received was not provided on an 
emergency basis, but for travel purposes. Therefore, we decided that the Plan does not have to pay for the 
COVID-19 test (87635) provided on November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 sensors. 
 
You asked the Plan to pre-approve Freestyle Libre 2 sensors. You say that the records provided support the 
need for the requested CGM supplies. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are 
considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three 
daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen 
and diabetes treatment plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
Freestyle Libre 2 sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Freestyle Libre 2 sensors.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral upper lid blepharoplasty and right upper lid 
ptosis repair for the enrollee. 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no photographs demonstrating the presence of true lid ptosis when 
excessive skin is elevated by taping. 
 
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 procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the case file does not contain documentation of each eye tested with the upper eyelid at rest and 
repeated with the lid elevated (e.g., taped or manually retracted), demonstrating an expected "surgical" 
improvement meeting or exceeding the criteria. In addition, photographs do not portray the eyelids in the 
frontal position demonstrating the upper eyelid skin resting on the eyelashes or over the eyelid margin. 
 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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral upper lid blepharoplasty and right upper lid ptosis repair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition, endoskeletal system, above knee or hip 
disarticulation, alignable system (L5920). 
You asked the Plan to pre-approve the alignable system. You say that you ask for approval to provide the total 
contact and alignable system to enhance the enrollee's overall health and longevity of life expectancy. The Plan 
denied your request. The Plan says the preparatory prosthesis is a non-alignable system and the medical 
necessity for the requested CPT code L5920- alignable system is not met. 
 
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 alignable system. 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 enrollee 
meets LCD criteria for the addition, endoskeletal system, above knee or hip disarticulation, alignable system 
(L5920). The preparatory prosthesis is a non-alignable system, therefore, the medical necessity for the 
requested alignable system (L5920) is not 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 the alignable system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the addition, endoskeletal system, above knee or hip disarticulation, alignable 
system (L5920).