Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1846). 
 
You asked the Plan to pre-approve the orthosis. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says the records provided does not show that the 
enrollee meets the criteria for the requested orthosis. 
 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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a custom knee orthosis (medial unloader brace, left knee) was requested as there was reported 
thigh calf mismatch and an inability to fit an off-the-shelf brace. However, as the documentation does not 
describe any significant objective instability of the left knee joint, the LCD requirements for Medicare 
coverage are 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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1846).
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 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. 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 while the enrollee may benefit from physical and occupational therapy, the enrollee's 
rehabilitation can be safely provided at a lower intensity and alternate setting such as a skilled nursing facility. Documentation does not support the necessity for admission to 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Skilled Nursing services. 
 
You asked the Plan to pre-approve the additional Skilled Nursing services. You say that you would like 
reconsideration because the requested Skilled Nursing services are medically necessary. The Plan denied your 
request. The Plan says the enrollee had been approved for services by another agency. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional Skilled Nursing services. 
Our reviewer says that the documentation doesnt support that the member requires additional skilled nursing 
services to provide treatment that is medically necessary. The member does not require additional skilled 
nursing services to effectively provide treatment, care, and/or services in order to improve the members 
condition, perform a maintenance program to maintain the members condition and/or prevent deterioration. 
The member has been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. Our physician reviewer found the requested visits appear to be a duplication of services that 
are not medically necessary. The requested home health services 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 the additional Skilled Nursing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional Skilled Nursing services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline. You do not 
require skilled nursing and/or skilled therapy services on a daily basis. Although further rehab services would 
be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than a skilled nursing 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on May 
20, 2020, through May 31, 2020 and billed with Patient Driven Payment Model (PDPM) score GAPE1 for 12 
days. 
 
You asked the Plan to pay for the SNF services billed with PDPM score GAPE1. You say that you would like 
reconsideration because the documentation supports the PDPM score billed. The Plan denied your request. The 
Plan says the documentation submitted does not support the PDPM score of GAPE1 for 12 days. 
 The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 SNF services billed with PDPM score 
GAPE1. Our reviewer says that the medical records do not support PDPM score GAPE1. Our physician 
reviewer found the records do not support a physical therapy/occupational therapy function score of 16, and a 
nursing function score of 12. 
 
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 SNF services billed with PDPM score GAPE1 have not been met. 
Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services 
provided on May 20, 2020, through May 31, 2020 and billed with Patient Driven Payment Model (PDPM) 
score GAPE1 for 12 days.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for T10 to pelvis fusion. The enrollee's medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for peripheral artery 
disease and had lower extremity stenting. The enrollees medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an angioplasty provided on May 27, 2021, 
surgical services, labs, medical supplies and anesthetics provided on May 27, 2021, hospital services, 
pharmacy, medical supplies and plasma expander provided on June 22, 2021. 
 
You asked the Plan to reimburse you for an angioplasty provided on May 27, 2021, surgical services, labs, 
medical supplies and anesthetics provided on May 27, 2021, hospital services, pharmacy, medical supplies and 
plasma expander provided on June 22, 2021. You say that all of these services were for emergency diabetes 
surgery and amputation of 2 toes. The Plan denied your request. The Plan says there are no medical records to 
document the emergency need for the services provided which is a requirement for covering worldwide 
healthcare services per EOC guidelines. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that the 
Plan does not cover out-of-network services rendered with the exceptions of the following: Emergency care or 
urgently needed services that you get from an out-of-network provider. This includes worldwide coverage if 
covered by your Plan. 
 
We looked at the file and the Plans rules. The file shows that you did not provide the Plan with the required 
medical records to determine the emergency need for these services. Therefore, we decided that the Plan does 
not have to reimburse you for an angioplasty provided on May 27, 2021, surgical services, labs, medical 
supplies and anesthetics provided on May 27, 2021, hospital services, pharmacy, medical supplies and plasma 
expander provided on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that you need these dentures because you 
cannot properly chew your food. The Plan denied your request. The Plan says these services are not covered 
under your benefit package. 
 
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 a 
maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbosacral facet joint injection rendered on August 25, 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 procedure code 64635 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that there is no postoperative work included in the fee 
schedule payment for the "ZZZ" codes.  
 
We looked at the file and Medicare rules. Billed procedure code 64635 has a global surgical period indicator of ZZZ and no separate payment when billed with primary code 64636. Therefore, we decided that the Plan does 
not have to pay for the lumbosacral facet joint injection rendered on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381), four 
gingival irrigations (D4921 x4), and two drugs or medicaments dispensed in the office for home use (D9630 
x2) provided on July 16, 2021. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents, gingival irrigations, and drugs or 
medicaments. You say that these services were medically necessary. The Plan denied your request. The Plan 
says these services are not covered expenses under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
localized delivery of antimicrobial agents (D4381), four gingival irrigations (D4921 x4), and two drugs or 
medicaments dispensed in the office for home use (D9630 x2) provided on July 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on September 8, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says inpatient care after August 23, 2021 was 
not medically necessary. 
 
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. Additionally, the record indicates that the provider was aware that this enrollee's inpatient 
stay was no longer covered on this date of service. 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 the critical care services 
(99291) provided on September 8, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guidance UTI test, Infectious agent detection by nucleic acid 
(DNA or RNA) (87481) provided September 24, 2021. 
 
You asked the Plan to pay for Guidance UTI test. You say that the physician ordered the medically necessary 
Guidance UTI test as the enrollee has a history of chronic urinary tract symptoms that have failed to resolve 
with standard treatment. The Plan denied your request. The Plan says this test is not FDA approved and 
therefore is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guidance UTI test have not been met. Therefore, we decided that the Plan does not have to pay for Guidance UTI test, Infectious agent detection by nucleic acid (DNA or RNA) (87481) provided September 24, 
2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the thyroid-stimulating hormone (TSH) testing provided 
on September 20, 2021. 
 
You asked the Plan to hold you harmless for the TSH testing. You say that you believe that this was incorrectly 
denied as you met your maximum out of pocket for the year. The Plan denied your request. The Plan says that 
you were told that this test would not be covered and agreed to receive it anyway. This means that the service 
was correctly denied. 
 
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. We find that the Plan did not submit sufficient documentation to support 
noncoverage for the testing at issue. Although the file includes a signed form indicating that the Plan may not 
pay for the testing, it does not definitively state that the testing cannot be covered. Without information from 
the ordering provider, we are not able to determine whether the denial is appropriate, according to Medicare 
guidelines. As such, we find that the denial is not substantiated in this case. Therefore, we decided that the Plan 
has to hold you harmless for the thyroid-stimulating hormone (TSH) testing provided on September 20, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation provided from September 15, 2021, 
through October 27, 2021. 
 
You asked the Plan to pay for electrical stimulation. You say that the claim description shows your share to be 
$45 in one place, $25 in another and $20 in another. You say that all the claims have the same issue, and your 
share is designated to be $20 in all places. The Plan denied your request. The Plan says the only chiropractic 
service covered is manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
  We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of electrical stimulation have not been met. Specifically, electrical stimulation is not a covered 
chiropractic service. Therefore, we decided that the Plan does not have to pay for electrical stimulation 
provided from September 15, 2021, through October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical stents (D5982 x2) and two interim implant 
crowns (D6085 x2). 
 
You asked the Plan to pre-approve the surgical stents and interim implant crowns. The Plan denied your 
request. The Plan says these services are not covered under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
surgical stents (D5982 x2) and two interim implant crowns (D6085 x2).