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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The 
enrollee's medical status does not require intensive physician or nursing supervision in an IRF. The enrollee 
may benefit from additional physical therapy (PT) and occupational therapy (OT) but does not require an 
intensive rehabilitation therapy program in an IRF.  
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a root canal on tooth #28 (D3320) provided 
on February 14, 2022, and porcelain crowns on tooth #27 and 28 (D2740) provided on February 21, 2022. We 
also decided the Plan does not have to pay for a periapical x-ray (D0220) provided on March 23, 2022. 
 
You asked the Plan to reduce the cost share for a root canal and crowns, and to pay for an x-ray. You say that 
you were overcharged for these dental services. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. The Plan also says that your benefit for a periapical x-ray has been 
exhausted. 
 
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 20% 
coinsurance for endodontic services.  
 
You have been asked to pay 20% coinsurance for the root canal provided on February 14, 2022, and crowns 
provided on February 21, 2022. 
 
Date of Service Code Allowed Amount 20% Coinsurance 
February 14, 2022 D3320 $444.75 $88.95 
February 21, 2022 D2740 $618.38 $123.67 
February 21, 2022 D2740 $618.38 $123.67 
 
A root canal and crowns fall 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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for a periapical x-ray was exhausted on date of service February 14, 2022. Therefore, we 
decided that the Plan does not have to reduce the cost share for a root canal on tooth #28 (D3320) provided on 
February 14, 2022, and porcelain crowns on tooth #27 and 28 (D2740) provided on February 21, 2022. We also 
decided the Plan does not have to pay for a periapical x-ray (D0220) provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMems device. 
 
You asked the Plan to pre-approve a CardioMems device. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. 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 CardioMems device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
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 CardioMems device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMems device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally-invasive lumbar decompression (MILD). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD is covered for beneficiaries enrolled in an 
approved clinical study. 
 
We looked at the file and Medicare rules. The records do not show that the procedure is being requested as part 
of an approved clinical study. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve minimally-
invasive lumbar decompression (MILD).
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. The enrollee 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 acute inpatient rehabilitation facility. There is no indication 
that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain his 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 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 a partial maxillary denture (D5213) provided by a 
participating provider. 
 
You asked the Plan to pay for the dental services. You say that you broke your denture, and you threw it out. 
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 date of service November 2, 2020. 
Therefore, we decided that the Plan does not have to pay for a partial maxillary denture (D5213) provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up (D5950) provided on August 5, 2021. 
 
You asked the Plan to pay for core build up. You say that this service was medically necessary. The Plan 
denied your request. The Plan says core build up (D5950) is not covered by your routine 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. 
 
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 core build 
up (D5950) provided on August 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex procedure. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 Vertiflex procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee the enrollee has chronic low back pain and lumbar spinal stenosis with 
neurogenic claudication. The record indicates that the enrollee has a body mass index of greater than 40. 
Therefore, the enrollee does not meet criteria for the requested 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Vertiflex procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this should be covered. The Plan denied your request. 
The Plan says this is not considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that the record indicates 
that the enrollee has a family history of breast cancer and a negative genetic screening. The record indicates 
that the enrollee's lifetime risk of breast cancer is less than 20%. The National Comprehensive Cancer Network 
(NCCN) guidelines recommends a screening breast MRI is recommended for patients with a residual lifetime 
risk greater than 20%. The requested service is not medically necessary and reasonable for the diagnosis and 
treatment for the enrollee's clinical condition at this tie. The elements of the coverage criteria are not satisfied. 
 
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 MRI have not been met.  
 
 
 
 Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the 
breast for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 physician reviewer 
found there is no documentation that the enrollee requires the services on an inpatient basis, only in a SNF 
setting. Records do not document services in the home with home health care or in a long-term care facility on 
a part time basis are not appropriate in this case. 
 
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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an amalgam (D2161) and a resin-based composite 
(D2394), provided by a participating provider on March 24, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel like the Plan should be paying for 
more. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for an amalgam (D2161) and a resin-based 
composite (D2394), provided by a participating provider on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments for tooth # 8, 9, 10, 12, 13, and 14 
(D6057), and for abutment supported porcelain fused to metal crown for tooth # 8, 9, 12, 13, and 14. 
 
You asked the Plan to pre-approve the custom abutments. You say that these services were approved last year, 
and you need an extension. You say that you need these services because you do not want to be without teeth. 
The Plan denied your request. The Plan says the services requested are not covered under your supplemental 
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. 
 
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 
custom abutments for tooth # 8, 9, 10, 12, 13, and 14 (D6057), and for abutment supported porcelain fused to 
metal crown for tooth # 8, 9, 12, 13, and 14.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient visit (99215) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient visit. You say that you have been seeing this physician for two 
years and would like to continue seeing them. The Plan denied your request. The Plan says the services have 
been requested out-of-network and in-network providers are available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an outpatient visit (99215) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve massage therapy services. You say that there are no in network massage 
therapists in your area. You say that you were assured by a plan representative that you could go out of network 
for these services. You also say that the requested provider knows how to work with your disabilities and keep 
you moving. The Plan denied your request. The Plan says there are in network providers available in your area. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there are 
network providers available who can provide the massage therapy services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan 
does not have to pre-approve massage therapy services to be provided by an out-of-network (OON) provider.
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 you will go backwards in recovery if you wait. You 
say if you do not go to inpatient rehabilitation your healing will be impacted. The Plan denied your request. 
The Plan says your records do not show that you are getting out of bed to shower or do activities by yourself. 
The services you need can be provided safely in other settings, for example, as 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 had a left lower foot/leg amputation on March 22, 2022 due to infection of 
the left foot and ankle extending into the leg. Per documentation from July 27, 2022, you were in a physical 
therapy program from June 13, 2022 to July 14, 2022. You had limited time out of bed despite education of the 
importance of this therefore a schedule could not be established. You were discharged due to limited 
participation in out of bed activities. While you have a need for physical 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.