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 this is the safest discharge plan, and it 
allows for the highest potential level of recovery. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care and does not require a transfer to an LTACH. 
 
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 patient does not require services at the LTACH that are not already available at 
the current facility. Our reviewer also found that transfer to an LTACH is not medically necessary as it would 
not be clinically advantageous. Completion of treatment at the current facility is recommended at this time. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional radiographic image (D0230) 
 
You asked the Plan to pay for a radiographic image. You say that you did not know that this provider was out-
of-network. The Plan denied your request. The Plan says D0230 has been 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.  
 
We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of a radiographic image have not been met. Therefore, we decided 
that the Plan does not have to pay for an additional radiographic image (D0230)
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies, life sustaining 
situation (A0422) provided July 20, 2021. 
 
You asked the Plan to pay for the oxygen supplies provided during ambulance transport. You say that the claim 
should be covered. The Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the cost of oxygen and its administration in connection 
with and as part of the ambulance service is covered.  Under the ambulance fee schedule (FS), oxygen and 
other items and services provided as part of the transport are included in the FS base payment rate and are NOT 
separately payable. pays for ambulance services only when an emergency exists or when other means of 
transport would endanger the patient's health. The Plan follows the same rules. 
 
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 oxygen supplies provided during ambulance transport have not been met. 
Specifically, the record shows the enrollee was provided emergency ambulance transport. The oxygen supplies 
provided during the ambulance transport are not separately billable. Therefore, we decided that the Plan does 
not have to pay for the ambulance oxygen and oxygen supplies, life sustaining situation (A0422) provided July 
20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies, life sustaining 
situation (A0422) provided September 16, 2021. 
 
You asked the Plan to pay for the oxygen supplies provided during ambulance transport. You say that the claim 
should be covered. The Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the cost of oxygen and its administration in connection 
with and as part of the ambulance service is covered.  Under the ambulance fee schedule (FS), oxygen and other items and services provided as part of the transport are included in the FS base payment rate and are NOT 
separately payable pays for ambulance services only when an emergency exists or when other means of 
transport would endanger the patient's health. The Plan follows the same rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen supplies provided during ambulance transport have not been met. Specifically, the 
record shows the enrollee was provided emergency ambulance transport. The oxygen supplies provided during 
the ambulance transport are not separately billable. Therefore, we decided that the Plan does not have to pay 
for the ambulance oxygen and oxygen supplies, life sustaining situation (A0422) provided September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit services (99205) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve office visit services. You say that this care is medically necessary. The Plan 
denied your request. The Plan says there are in-network providers available to provide the requested medical 
care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit services (99205) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
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 medically reasonable and necessary. Our physician reviewer found the enrollee is an 
81-year-old male with a past medical history of atrial fibrillation, stroke, benign prostatic hyperplasia and 
depression who presented to the acute hospital on May 17, 2022, with hypoactive delirium and major 
depression. In this case, there is no documentation that the patient requires skilled nursing services. While, this 
patient does require skilled therapy services, there is no documentation that these services are required on a 
daily basis. The patient is walking greater than household distances with a rolling walker with mostly 
supervision/stand-by assistance and is stand-by assist for transfers. Provided records do not document a 
significant decline in the patients functional status to necessitate daily inpatient skilled therapy services. In 
conclusion, there is no documentation that the patient requires the services on an inpatient basis, only in a 
skilled nursing facility setting. Services in another setting would be more appropriate. 
 
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 admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that this drug is medically reasonable for the enrollee's 
condition. The Plan denied your request. The Plan says there is no indication that the enrollee's condition has 
improved since starting Entyvio. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Entyvio. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the provider has 
requested this drug to be given every 6 weeks. However, Entyvio may only be continued if there is evidence of 
therapeutic benefit after the first 14 weeks of treatment. There is no documentation of therapeutic benefit. The 
review has determined that the documentation does not support that Entyvio is medically reasonable and 
necessary for the patient. The documentation does not support that Entyvio is safe and effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a consultation visit provided on August 24, 2021. 
 
You asked the Plan to pay for consultation visit. You say that you are appealing this denial. The Plan denied 
your request. The Plan says that the denial of payment for this service is correct, because this claim was not 
billed with the appropriate Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers who bill for telehealth services may 
report the place of service that would have been reported had the service been furnished in person.  
 
We looked at the file and Medicare rules. The record shows that this telehealth service was provided in place of 
an in-person visit in the setting of the COVID-19 public health emergency. This claim was billed with Place of 
Service (POS) code 19, representing an off-campus outpatient hospital setting. The rendering facility is an off-
campus outpatient hospital facility. Therefore, the place of service that would have been reported had the 
service been furnished in person is Place of Service (POS) code 19. Therefore, this claim was billed in 
accordance with Medicare rules in the setting of the COVID-19 public health emergency. The Plan must make 
appropriate payment for this service at the same rate they would have paid if the service was furnished in 
person. Based on this information, we decided that Medicare rules for coverage of consultation visit have been 
met. Therefore, we decided that the Plan has to pay for a consultation visit provided on August 24, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitoring system.
You asked the Plan to pre-approve the CGM. You say that the records should support the necessity of the item in dispute. The Plan denied your request. The Plan says this item is not listed on the preferred diabetic supply.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The records do not show that the enrollee has used and failed the preferred Freesyle Libre, continuous glucose monitor. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitoring system.
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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. 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 a thoracic compression fracture after a fall. 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, in 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. 
 
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. 
 
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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. 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 coronary artery bypass grafting 
and aortic valve replacement. 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, in 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. 
 
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. 
 
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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. 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 right facial droop and right arm weakness. 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, in 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endodontist consultation and root canal. 
 
You asked the Plan to pre-approve a consultation and root canal. You say that you are in pain when drinking 
anything cold. You also say you only have five teeth, and you need to keep your bridge. The Plan denied your 
request. The Plan says dental services must be performed by a participating general dentist; therefore, services 
by an endodontist are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit when not performed by a participating general dentist. Therefore, we 
decided that the Plan does not have to pre-approve an endodontist consultation and root canal.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for one resin-based composite filling. We also decided that the Plan does 
not have to pay for three resin-based composite fillings.  
 
You asked the Plan to pay for the fillings. You say that you would not have had these procedures so close to the 
new year if you had not gotten the go ahead. The Plan says that a filling is covered by the Plan's dental benefits; 
however, your benefit for two procedures per calendar year has been exhausted. 
 
 We decided that the Plan has to pay for one resin-based composite filling.  
 
The Plan says that your dental benefit for two fillings has been exhausted. The record shows that the Plan only 
paid for one filling on December 6, 2021. Therefore, we decided that the Plan has to pay for one resin-based 
composite filling provided on December 23, 2021.  
 
We also decided that the Plan does not have to pay for three resin-based composite fillings. 
 
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 two fillings 
per calendar year. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan only paid for one 
filling provided on December 6, 2021, and we decided to tell the Plan to pay for one filling provided on 
December 23, 2021; therefore, the benefit for two fillings have been exhausted. Therefore, we decided that the 
Plan does not have to pay for two resin-based composite fillings provided on December 23, 2021, and one 
resin-based composite filling provided on December 28, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve implants. You say that the dental implants are medically necessary. The 
Plan denied your request. The Plan says dental implants are not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower partial denture- cast metal framework with resin 
denture base (D5214). 
 
You asked the Plan to pre-approve lower partial denture- cast metal framework with resin denture base. You 
say that you need new bottom dentures because you accidentally lost them. The Plan denied your request. The 
Plan says this service exceeds the maximum count allowed per period. 
 
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. The Plan contract says that there is one allowed lower partial denture- 
case metal framework with resin denture base  every five plan years. Therefore, we decided that the Plan does 
not have to pre-approve lower partial denture- cast metal framework with resin denture base (D5214).