Persius/hicric huggingface dataset:
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 you are requesting reconsideration for 
the denial of an LTACH admission due to medical necessity. The Plan denied your request. The Plan says the 
request for coverage for admission to an LTACH is being denied as 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint corticosteroid injection. 
 
You asked the Plan to pre-approve a sacroiliac joint corticosteroid injection. You say that a sacroiliac joint 
corticosteroid injection is medically necessary. The Plan denied your request. The Plan says the requested 
sacroiliac joint corticosteroid injection is not medically necessary. 
 
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 a sacroiliac joint corticosteroid 
injection. Our reviewer says that the requested sacroiliac joint corticosteroid injection is not considered 
medically reasonable and necessary. Our physician reviewer found that sacroiliac joint (SIJ) injections are 
recommended as an option if the patient has failed at least 4-6 weeks of aggressive conservative therapy 
including, physical therapy (PT), home exercise and medication management. There should be evidence of a 
clinical picture that is suggestive of sacroiliac injury and/or disease. At least three (3) positive exam findings of 
SI joint dysfunction should be present on physical exam such as: Patrick's test, thigh thrust, SI compression 
test, Yeoman's test, or Gaenslen's test. In this case, there is no documentation of any failure of 4-6 weeks of 
aggressive conservative therapy including physical therapy and a home exercise program. In addition, the clinical value and effectiveness of an SI joint injection in the absence of tenderness and negative provocative 
testing results have not been demonstrated in the peer-reviewed literature. The review has determined that the 
service at issue is not medically reasonable or 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 sacroiliac joint corticosteroid injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a sacroiliac joint corticosteroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower. 
 
You asked the Plan to pre-approve the requested service. You say that you have a hard time getting in and out 
of the tub. The Plan denied your request. The Plan says the item is not 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 walk-in shower.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on October 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was necessary to assess the cause of 
your pain. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 14, 2022. Therefore, 
we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on October 10, 2022.
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 member would benefit from short term IRF to 
improve functional mobility. The Plan denied your request. The Plan says the IRF services requested do not 
meet the definition of medical necessity. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a pneumatic compression device (E0675) provided on August 12, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you disagree with 
the denial and have submitted medical records for review. The Plan denied your request. The Plan says 
pneumatic compression devices are covered in the home setting when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. Pneumatic 
compression devices are not covered by Medicare when the place of service is an ambulatory surgical center. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. The records show that you billed with place of service 
24, which is an ambulatory surgical center. Medicare rules state that for durable medical equipment to be 
covered, it must be appropriate and be needed for use inside the home. The PCD's were billed for use outside of 
the home and is not separately payable. Therefore, we decided that the Plan does not have to pay for a 
segmental gradient pressure pneumatic appliance, half leg (E0673) and a pneumatic compression device 
(E0675) provided on August 12, 2022.
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 enrollee meets criteria for admission. The Plan 
denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chronically ill benefits. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is unable to work. The Plan 
denied your request. The Plan says the coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. The records provided do not show that the enrollee meets the 
coverage criteria of being high risk and requiring intensive care management. The records do not show that the 
enrollees condition is life threatening or significantly limits overall health/function.  Based on this information, we decided that Medicare rules for coverage of the requested services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve chronically ill benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost nutritional supplements. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has Rheumatoid arthritis. 
The Plan denied your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Boost nutritional supplements.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a pneumatic compression device (E0675) provided on August 2, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you disagree with 
the denial and have submitted medical records for review. The Plan denied your request. The Plan says 
pneumatic compression devices are covered in the home setting when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. Pneumatic 
compression devices are not covered by Medicare when the place of service is an ambulatory surgical center. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. The records show that the place of service billed was 
24, which is an ambulatory surgical center. Medicare rules state that for durable medical equipment to be 
covered, it must be appropriate and be needed for use inside the home. The PCD's were billed for use outside 
of the home and is not separately payable. Therefore, we decided that the Plan does not have to pay for a 
segmental gradient pressure pneumatic appliance, half leg (E0673) and a pneumatic compression device 
(E0675) provided on August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a pneumatic compression device (E0675) provided on August 4, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you disagree with 
the denial and have submitted medical records for review. The Plan denied your request. The Plan says 
pneumatic compression devices are covered in the home setting when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. Pneumatic 
compression devices are not covered by Medicare when the place of service is an ambulatory surgical center. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. The records show the place of service billed was 24, 
which is an ambulatory surgical center. Medicare rules state that for durable medical equipment to be covered, 
it must be appropriate and be needed for use inside the home. Therefore, we decided that the Plan does not 
have to pay for a segmental gradient pressure pneumatic appliance, half leg (E0673) and a pneumatic 
compression device (E0675) provided on August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that given the enrollee's complex condition and risk of 
further medical complications, rehabilitation services cannot be safely or effectively provided at a lower level 
of care such as a skilled nursing facility. The Plan denied your request. The Plan says criteria for admission to 
the IRF setting 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the enrollee is having a lot of pain. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions are only covered if certain 
criteria are met. 
 
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 facet joint injections. Our reviewer says 
that the enrollee does not meet the criteria for the requested facet joint injections. Our physician reviewer found 
the records do not include documentation of moderate to severe chronic neck pain - predominantly axial - that causes functional deficit measured on pain or disability scale and has been present for a minimum of 3 months 
with documented failure to respond to noninvasive conservative 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

  
We decided that the Plan does not have to pre-approve an implant supported crown (D6065) and prefabricated 
abutment (D6056). 
 
You asked the Plan to pre-approve an implant supported crown and prefabricated abutment . You say that you 
are missing two teeth and need all your teeth to eat better. You say that this is very important for your 
appearance. The Plan denied your request. The Plan says these are covered services when certain criteria is met 
but they cannot be provided together. 
 
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 can be covered 
under this benefit when certain criteria are met. In this case, these services cannot be performed together, and a 
new request should be submitted with the appropriate services that are required. Therefore, we decided that the 
Plan does not have to pre-approve an implant supported crown (D6065) and prefabricated abutment (D6056).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the skilled nursing facility (SNF) care 
provided from January 19, 2022, to January 31, 2022 
 
You asked the Plan to waive the coinsurance for the SNF care. You say that the facility is an in-network 
provider. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 50% 
coinsurance per stay for each Medicare-covered SNF stay when out-of-network. The total allowed amount was 
$8,834.25 with a coinsurance amount of $4,417.12 ($8,834.25 total amount x 50% coinsurance). 
 
  The enrollee has been asked to pay a $4,417.12 coinsurance for the SNF care. This item/service falls within 
skilled nursing facility (SNF) care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the skilled nursing facility (SNF) care provided from January 19, 2022, to January 31, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for dental care. 
 
You asked the Plan to pre-approve anesthesia services. You say that the enrollee is high risk. The Plan denied 
your request. The Plan says the requested service is not a covered benefit. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve anesthesia 
for dental care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral facet joint radiofrequency ablations (RFA) 
(64635).  
You asked the Plan to pre-approve the surgical procedure. You say that please see medical records attached for 
the appeal. The Plan denied your request. The Plan says the clinical information provided does not show the 
enrollee meets the criteria 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had an RFA performed on April 8, 2021, and October 20, 2020, at 
Bilateral L4-L5. The RFA performed on April 8, 2021, provided no benefit past 8 weeks. A successful RFA 
should provide analgesia for at least 6 months. These RFA have not provided that duration of relief.  Therefore, 
the request is deemed not medically reasonable and 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral facet joint radiofrequency ablations (RFA) (64635).