Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture. 
 
You asked the Plan to pre-approve the upper partial denture. You say that your teeth got cracked and were 
successfully removed. You say that you can't eat food without this. The Plan denied your request. The Plan 
says a partial denture 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 Plan?s coverage rules apply in this case. The Plan covers the upper 
partial denture 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 the upper partial denture. Our reviewer 
says as there are eight posterior contacts present, the Plan criteria for having less than eight posterior contacts 
to approve another partial denture have not been met.  
 
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 upper partial denture have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upper partial denture.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee only requires 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. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy (PT) services you 
received on July 22, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you haven't been charged for 
these services in the past. The Plan denied your request. The Plan says you were charged this copayment 
correctly.  The provider may have provided previous services without a copayment as a courtesy. 
 
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 a $30 
copayment for physical therapy services.  
 
You have been asked to pay a $30 copayment for the PT services. 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. Therefore, we decided that the Plan does not have to waive the 
copayment for the physical therapy (PT) services you received on July 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo for the enrollee. 
 
You asked the Plan to pre-approve Opdivo. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the clinical value and effectiveness of Opdivo being used as single 
agent (not in combo with ipilimumab) in the setting of Malignant Pleural Mesothelioma as first line treatment 
has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Opdivo. Our reviewer says that Opdivo 
is not medically reasonable and necessary for the enrollee. Opdivo is not FDA-approved for the enrollee?s 
diagnosis. The use of Opdivo as first line therapy is not supported by one of the major drug compendia or by 
clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of Opdivo. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided July 26, 2021.

You asked the Plan to pay for the full mouth debridement. You say that you are displeased with this dentist and would like the service covered. The Plan denied your request. The Plan says this service is not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided July 26, 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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 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: 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 admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.

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 undergoing additional workup and treatment and is not
stable for transfer at this time. The enrollee does not require services at the LTACH that are not already
available at the current facility. There are no services at the LTACH that the enrollee requires that are not
already available and covered at the current 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided on June 10, 2021 by an out-of-network
(OON) provider.

You asked the Plan to pay for the x-ray. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the services provided are not a covered benefit.

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 the x-ray provided on June 10, 2021 by an out-of-network
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth, or exposed root (elevation 
and/or forceps removal) (D7140), deep sedation/general anesthesia  first 15 minutes (D9222) and deep 
sedation/general anesthesia  each subsequent 15-minute increment (D9223) provided May 21, 2021. 
 You asked the Plan to pay for the tooth extraction and anesthesia. You say that the services were medically 
necessary because you were in pain. The Plan denied your request. The Plan says the provider who rendered 
the services has opted out of Medicare and therefore the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the tooth 
extraction and anesthesia when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The provider who rendered the services at issue has opted out of the 
Medicare program. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth, 
or exposed root (elevation and/or forceps removal) (D7140), deep sedation/general anesthesia  first 15 
minutes (D9222) and deep sedation/general anesthesia  each subsequent 15-minute increment (D9223) 
provided May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4), two drugs or 
medicaments dispensed in the office for home use (D9630 x2), comprehensive oral evaluation (D0150), and 
complete series of intraoral x-rays (D0210) provided on July 2, 2021. 
 
You asked the Plan to pay for the gingival irrigations, drugs or medicaments, comprehensive oral evaluation, 
and complete series of intraoral x-rays. You say that the gingival irrigations were necessary for the scaling 
procedures, and the explanation of benefits for the drugs or medicaments is unclear. You also say that because you were seen by a new dentist the comprehensive oral evaluation and complete series of intraoral x-rays were 
necessary and should be covered. The Plan denied your request. The Plan says the gingival irrigation and drugs 
or medicaments are not covered expenses under your Dental plan. The Plan also says that your benefits for the 
comprehensive oral evaluation and complete series of intraoral x-rays have been satisfied and the frequency 
limitations have been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, gingival irrigation (D4921) and drugs 
or medicaments dispensed in the office for home use (D9630) are not among those covered under this benefit. 
The contract clearly states that comprehensive oral evaluation (D0150) is limited to one procedure code every 
three years, and full mouth (D0210) or panoramic x-rays (D0330) share a frequency limitation of one 
procedure code every five years. The record shows that you received a comprehensive oral evaluation (D0150) 
and panoramic x-rays (D0330) on October 4, 2019 and your comprehensive oral evaluation (D0150) and full 
mouth (D0210) or panoramic x-rays (D0330) benefits have been exhausted. Therefore, we decided that the 
Plan does not have to pay for the four gingival irrigations (D4921 x4), two drugs or medicaments dispensed in 
the office for home use (D9630 x2), comprehensive oral evaluation (D0150), and complete series of intraoral 
x-rays (D0210) provided on July 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee scooter (E0118) and sales tax (S9999), provided on 
June 12, 2021. 
 
You asked the Plan to pay for the knee scooter and sales tax. You say that the items should be covered. The 
Plan denied your request. The Plan says the items are not covered benefits and you received the items through a 
provider that is not certified with Medicare. 
 The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the knee scooter (E0118) and sales tax 
(S9999), provided on June 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-five (25) additional PT visits.
You asked the Plan to pre-approve twenty-five (25) additional PT visits. You say that additional PT is
medically necessary. The Plan denied your request. The Plan says additional PT is 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 twenty-five (25) additional PT 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 in this case, the enrollee has
previously been treated with outpatient therapies and should be independent with a home exercise program.
There is no documentation of a recent injury or decline in function. The additional therapy services are not an
appropriate duration and frequency for treatment of the enrollee's medical condition and therefore 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 twenty-five (25) additional PT visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve twenty-five (25) additional PT visits.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 hrs. per day of home health aide services.
You asked the Plan to pre-approve 3 hrs. per day of home health aide services. 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 HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or 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 3 hrs. per day of home health aide
services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the
review documentation indicates that enrollee no longer meets the eligibility for the requested home health aide
(HHA) services but that the enrollee will be approved for 3 HHA hours per week thru the end of the
certification period of December 28, 2021. The review has determined that the services do not meet the
definition of home health aide services as per Sections A, B, C, D & E of Section 50.2. The requested home
health aide services are not reasonable and necessary to the treatment of the enrollee's illness or injury by the
skilled professional staff.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 3hrs per day of home health aide services have not been met. Therefore, we
decided that the Plan does not have to pre-approve 3 hrs. per day of home health aide services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your request. The Plan says that the services can be safely received in another setting, for example, home with home health, in residential care, or home with close follow-up.
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 admission is medically reasonable and necessary. Our physician reviewer found the enrollee does qualify for SNF coverage. The enrollee does not have documented skilled nursing needs, though monitoring for surgical site infections and pressure sore development is reasonable. he enrollee does have documented skilled therapy needs. While the enrollee is currently non-weight bearing, upper extremity exercise, transfer training and occupational therapy are performable. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition, with a plan for future weight bearing progression. The enrollee's care needs, as a practical matter, cannot 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
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 necessary and appropriate for this enrollee's recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the necessary services in 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. Our physician reviewer found that 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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.