Persius/hicric huggingface dataset:
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 enrollee has been medically stable for discharge. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for admission to a 
SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says 30 additional 
physical therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee can continue with their effective home 
exercise program. Continued services from a skilled therapist are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 30 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service July 16, 
2022. 
 
You asked the Plan to pay for procedure code 12001. You say that these codes are appropriately identified as 
separate services and payment for the previously denied procedure should be made. The Plan denied your 
request. The Plan says payment for code 12001 is bundled into payment for code 26750. 
 
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, we have confirmed that code 12001 
is a column II code to column I code 26750. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 12001 billed for date of service July 16, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2750) for tooth #23, #24, and #26. 
 
You asked the Plan to pre-approve D2750. You say that you need this dental work. The Plan denied your 
request. The Plan says that the medical criteria for D2750 have not been met. 
 
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 has failed to provide dental x-rays. Therefore, we decided that the Plan 
has to pre-approve a crown (D2750) for tooth #23, #24, and #26.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on October 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was for use during surgery. The 
Plan denied your request. The Plan says the devices are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The services at issue were provided in an ambulatory surgical center. 
Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device and related supplies provided 
on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (99219, 99235) provided on January 27, 
2022 to January 28, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient services have been met. 
No clinical records were provided for the dates of service at issue. Therefore, we decided that the Plan does not 
have to pay for outpatient services (99219, 99235) provided on January 27, 2022 to January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E1230). 
 
You asked the Plan to pre-approve a power scooter. You say that the enrollee has difficulty standing or walking 
for long periods of time as it makes her feel short of breath, winded and severe pain. She uses both a walker 
and a cane to get around as she cannot put any pressure on her left leg. The enrollee has not been able to go out 
and do her normal activities because it is too difficult for her to get around without a scooter. Using a scooter 
would improve her mobility for her everyday activities. The Plan denied your request. The Plan says Medicare 
requires specific documentation of the enrollee's medical condition, impairment and need for a power mobility 
device in addition to specific evaluations be done in order for this device to be covered. The enrollee is not in 
need of a power vehicle to perform activities of daily living within her home. 
 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.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. The enrollee 
is able to walk household distances with the help of a cane but needs the scooter to go longer distances outside 
of the home. The records show that the enrollee has not completed the necessary specialty home evaluation nor 
provided the appropriate documentation for approval of this device. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power scooter (E1230).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you are bed-bound and the only way that 
you can get to physical therapy (PT) is with a wheelchair ramp. You were receiving in home therapy, but they 
were unable to assist you. You also say that if you are able to get out of the home for PT, you would be able to 
walk again sooner. The Plan denied your request. The Plan says a wheelchair ramp is a convenience item and 
not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white glass crown (D2752) for tooth #12. 
 
You asked the Plan to pre-approve a crown. You say that you need this crown. The Plan denied your request. 
The Plan says the medial criteria for D2752 have not been met. 
 
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 a crown 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 a crown. Our reviewer says that  Our 
physician reviewer found the documentation provided does not meet the criteria for coverage for a crown 
restoration (D2752) for tooth #12. 
 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 a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a white glass crown (D2752) for tooth #12.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22513). 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that this is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage. 
 The Plan follows 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 percutaneous vertebral augmentation. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found imaging studies 
show that the fracture is more than 6 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation (22513).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires daily physician 
visits, specialty consultations, and daily laboratory monitoring. The Plan denied your request. The Plan says 
criteria for admission to the LTACH 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 all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0480) provided on November 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are in-network with the commercial plan. The 
Plan denied your request. The Plan says these services were performed by an out-of-network provider. Out-of-
network services are covered only in certain limited circumstances, which have not been met in this case. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for drug testing (G0480) provided on November 15, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit provided on November 25, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were provided and billed correctly 
under the supervision of the physician. The Plan denied your request. The Plan says that the claim needs to be 
re-billed under the supervising physician as per CMS rules regarding Physician Assistant/Nurse Practitioner 
coverage. 
 
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 has not provided a valid Medicare rule or a coding rule to substantiate 
their denial. Therefore, we decided that the Plan has to pay for an office visit provided on November 25, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozurdex. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of 
cystoid macular degeneration. The Food and Drug Administration (FDA) has not stated that the requested drug 
is indicated for the enrollee's condition. The Medicare-approved  drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. Ozuredex is therefore not 
reasonable and medically necessary.  
We looked at this physician's review, the file, and Medicare rules. 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 Ozurdex.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown and core buildup. 
 
You asked the Plan to pre-approve dental crown and core buildup. You say that the enrollee is in a lot of pain. 
The Plan denied your request. The Plan says there is no natural tooth so these are not appropriate 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. The Plan covers dental crown 
and core buildup 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 dental crown and core buildup. Our 
reviewer says that the enrollee does not meet criteria for the requested dental services. Our physician reviewer 
found the area of tooth #12 has a dental implant and an implant abutment supported crown in place. There does not appear to be any defect requiring a new crown to be placed. No narrative was presented indicating why a 
new crown is needed. 
 
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 dental crown and core buildup have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a dental crown and core buildup.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair ramp and sales tax received on August 11, 
2022. 
 
You asked the Plan to pay for the wheelchair ramp and sales tax. You say that you have foot surgery and are 
unable to use your right foot for at least three months. The Plan denied your request. The Plan says the item 
received is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the wheelchair ramp and sales tax received on August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says ventilators used to provide continuous 
positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) therapy will be denied as not 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has a diagnosis of COPD, but the medical records do not include pulmonary 
function tests to assess severity.  There is no arterial blood gas, done while stable, showing carbon dioxide 
(CO2) retention. If this enrollee has severe COPD and chronic CO2 retention, may benefit from bilevel positive 
airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. A home ventilator is not 
medically necessary. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466).