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 the enrollee meets the guidelines for 
coverage of LTACH care. You say that the enrollee is expected to require 2-3 weeks to transition from him 
acute illness. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval of LTACH care. The Plan says that the enrollee is not yet ready to leave the hospital, and that when 
she is she can safely receive the care needed in a setting such as a skilled nursing facility. 
 
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 the enrollee was admitted acute hypoxic respiratory failure due to COVID-19 
infection. The record indicates that the enrollee is still acutely ill and requires ongoing acute care services. The 
enrollee continues to receive acute care services, and these have not been denied.  
  
The medical record does not indicate that the enrollee requires services that he is not currently receiving but 
that would be available at the LTACH facility. 
 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says clinical information was not submitted to show that the 
member failed a reasonable trial of a basic pump (E0650/E0651) prior to requesting the advanced pump 
(E0652). 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the literature indicates that proton beam therapy is not the standard of care 
for prostate cancer. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found any potential benefit or detriment of proton therapy over standard intensity-modulated radiation therapy 
(IMRT) is an investigational question (being pursued in randomized studies- i.e. for intermediate to low risk 
prostate cancer. Other treatment approaches (IMRT +/- IGRT) are also highly effective and well 
tolerated.  Thus, whether proton therapy affords a benefit over other standard approaches (IMRT/IGRT) for 
prostate cancer is an area of investigation and remains controversial. To date, there are no compelling data to 
suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard 
of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy for the enrollee.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 enrollee does not require at least 3 hours a day/5 days a week, or 15 hours over 7 
consecutive days, of therapy services. Therapy services may 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 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 continued (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is still non-
ambulatory after more than 60 days of therapy; although he has made some improvements, daily skilled 
therapy no longer appears to be indicated. The enrollee does not require the services on an inpatient basis, only 
in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210) and comprehensive oral 
evaluation (D0150) provided from September 2, 2021, to October 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have not received benefits for this service 
that was denied. You say that you are having your teeth and gums prepped to receive partial dentures. You also 
say that you need these claims to be paid. The Plan denied your request. The Plan says the claims were 
processed correctly. 
 
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 frequency limits have been exceeded. The file shows that 1 comprehensive oral evaluation is covered every 
3 years and 1 complete series or panoramic x-ray is covered every 5 years. The file shows that the Plan paid for 
a comprehensive oral evaluation and panoramic x-ray that you received on June 14, 2021. Therefore, we 
decided that the Plan does not have to pay for the complete series x-ray (D0210) and comprehensive oral 
evaluation (D0150) provided from September 2, 2021, to October 5, 2021.
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 clinical documentation provided 
supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of 
LTACH care have not been met. The Plan says that the services needed could be provided in another setting. 
 
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 the enrollee appears to be improving but requires only short-term additional acute 
care services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary as 
it would not be clinically advantageous. Transfer may be considered when treatment has completed. 
 
 
 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: 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 states the 
services you require therapy to make you stronger, can safely be received at a different setting, for example, 
home with home health, in residential care, or home with close follow-up with your doctor. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, custodial and intermittent, can 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 you are coming from the hospital and have not been 
able to meet your normal day living functions. You state you are unable to walk on your own and are 
wheelchair bound and need the services immediately or you will be prone to decline. You state that with 
rehabilitation, you are expected to be able to walk. The Plan denied your request. The Plan says the stay is not 
medically necessary based on SNF criteria. The Plan states transfer to a SNF for inpatient skilled rehabilitation 
services 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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to 
be at/near a new baseline of function. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a 
practical matter, 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on June 30, 2021 to July 
29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that patient patient status code 06 must be billed on claims 
where the patient elects MA coverage during an HH PPS period of care. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required patient 
status code 06. 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 pay for the home health services rendered 
on June 30, 2021 to July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing services provided on July 21, 2021. 
 
You asked the Plan to pay for the testing services. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed services were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim lists a place of service as an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the specimen was obtained at an independent laboratory. Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the Guardant360 testing services provided on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2790) for tooth # 18 provided on July 13, 2021. 
 
You asked the Plan to pay for the dental service. You say that the crown is medically necessary. The Plan 
denied your request. The Plan says the crown for tooth # 18 is not medically necessary. 
 
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 the dental 
service 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 pay for the dental service. Our reviewer says that the 
crown for tooth # 18 is not medically necessary. Our physician reviewer found the provided record is 
insufficient to establish that the coverage criteria are satisfied for the requested service. 
 
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 the dental service have not been met. Specifically, the file does not have 
sufficient information to support the the requested service is medically necessary. Therefore, we decided that 
the Plan does not have to pay for the crown (D2790) for tooth # 18 provided on July 13, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is 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 the complexity of the enrollees nursing, medical, and rehabilitation needs does 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. However, the 
available documentation does not support that the enrollee will tolerate at least 3 hours per day for 5 days per 
week (or 15 hours over 7 consecutive days) of therapy services. There is not a reasonable expectation that the 
enrollee will be able to fully participate in  or benefit from  the intensive rehabilitation therapy program 
provided 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 inpatient rehabilitation facility (IRF) admission and services.
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 reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You were previously receiving enteral feeds at home. You do not 
have documented skilled therapy needs. You are dependent for mobility and appear unable to participate in 
skilled therapies. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs can, as a practical matter, 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from March 10, 2022, 
forward. 
 
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 reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you no longer qualifies for SNF coverage. 
You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You 
are ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from March 10, 2022, forward.