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 the enrollee is medically stable and ready 
for the LTACH level of care. The Plan denied your request. The Plan says LTACH services are 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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 heavy duty, single power 
option, captain's chair, patient weight capacity 301 to 450 pounds (K0859), a group 34 sealed lead acid battery 
(E2359x2), a manual swing away, retractable, or removable mounting hardware for joystick (E1028), a power 
seating system, tilt only (E1002), an electronic connection between wheelchair controller and two or more 
power seating system motors (E2311) and an addition to power seating system, center mount power elevating 
leg rest/platform, complete system (E1012). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary for the enrollee. The Plan denied your request. The Plan says the 
requested item and accessories are not medically necessary as Medicare criteria are not met. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found Enrollee with obesity and chronic back pain has requested a group 3 
power wheelchair. She is currently able to perform transfers with supervision, bathe, and dress herself. She has 
adequate upper body strength to perform her ADLs. The enrollee does not require a group3 power wheelchair. 
She has adequate upper body strength to manage power switches, has no spasticity, skin breakdown or high 
risk of skin breakdown and does not use a catheter per L33789. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 3 heavy duty, single power option, 
captain's chair, patient weight capacity 301 to 450 pounds (K0859), a group 34 sealed lead acid battery 
(E2359x2), a manual swing away, retractable, or removable mounting hardware for joystick (E1028), a power 
seating system, tilt only (E1002), an electronic connection between wheelchair controller and two or more 
power seating system motors (E2311) and an addition to power seating system, center mount power elevating 
leg rest/platform, complete system (E1012).
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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
admission to an IRF. 
 
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 an IRF admission is not medically necessary based on lack of medical complexity 
and identified skilled rehabilitation nursing needs. While you may benefit from physical and occupational 
therapy, your therapy needs can be provided safely in a low intensity alternate setting such as in 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts (A5500, A5513). 
 
 
You asked the Plan to pre-approve diabetic shoes and inserts. You say that you need these items because you 
have diabetes and a decreased feeling in your feet. You also say that you are prone to falling. The Plan denied 
your request. The Plan says these items are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes and inserts (A5500, 
A5513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T). 
 
You asked the Plan to pre-approve injections. You say that the enrollee's medical diagnosis may benefit from 
this procedure. The Plan denied your request. The Plan says the request is not medically necessary because 
there is little evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's 
back pain. It is not an accepted standard of medical practice for the diagnosis or treatment of back pain. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain. She has tried physical therapy, epidural steroid 
injections and medial branch blocks. Imaging of L1-L3 shows degenerative changes. This is an experimental/ 
investigational procedure. 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, 
unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (0627T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nonsurgical treatment for blocked nerve canal (D3331) 
and nerve treatment planning and diagnosis (D3332). 
 
 
You asked the Plan to pre-approve nonsurgical treatment for blocked nerve canal and nerve treatment. You say 
that this should be covered. The Plan denied your request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 nonsurgical treatment for blocked nerve canal (D3331) and nerve treatment planning and diagnosis (D3332).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture  resin base (D5211), mandibular 
partial denture  resin base (D5212), extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth (D7210 x3), and repair resin partial denture base, maxillary (D5612) provided on January 4, 2022, and 
November 21, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D5211, D5212, D7210 and D5612. You 
say that you were under the impression you had dental coverage. The Plan denied your request. The Plan says 
these services are not covered under the 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 pay for a 
maxillary partial denture  resin base (D5211), mandibular partial denture  resin base (D5212), extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x3), and repair resin partial denture 
base, maxillary (D5612) provided on January 4, 2022, and November 21, 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 you need physical and occupational therapy services 
to help you regain your strength. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and your needs can be met in another setting. 
 
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 you are medically stable and do not require close supervision for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. While you can benefit from 
physical and occupational therapy, your needs can be safely provided in an alternate level of care such as 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements for admission to an 
IRF. 
 
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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While enrollee may have a need for physical therapy 
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. There is not a reasonable expectation that the 
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 an IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 21, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the claim 
should be paid as you passed out and did not call for the ambulance. The Plan denied your request. The Plan 
says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service September 
16, 2022. 
 You asked the Plan to pay for the billed services. You say that the codes are separate procedures. The Plan 
denied your request. The Plan says code 99285 is included with the minor surgery procedure when billed 
without an appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99285 is not supported. Specifically, the claim was not billed to indicate the evaluation 
and management service was a separately identifiable service from minor procedure code G0168. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical fluoride varnish (D1206), pre-diagnose test to aid in 
detection of mucosal abnormalities (D0431) and periodontal maintenance procedures (D4910) provided on 
December 7, 2022. 
 
You asked the Plan to pay for topical fluoride varnish, test to aid in detection of mucosal abnormalities and 
periodontal maintenance procedures. You say that this should be covered. The Plan denied your request. The 
Plan says these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 topical 
fluoride varnish (D1206), pre-diagnose test to aid in detection of mucosal abnormalities (D0431) and 
periodontal maintenance procedures (D4910) provided on December 7, 2022.
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 have pneumonia, acute respiratory 
failure, and unhealing wounds and you need to be given proper care. The Plan denied your request. The Plan 
says the requested LTACH services are 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 that 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation 
(TMS) treatment; initial (90867), therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; 
subsequent delivery and management, per session (90868) and therapeutic repetitive transcranial magnetic 
stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management 
(90869). 
 
You asked the Plan to pre-approve TMS treatment. You say that TMS is medically necessary. The Plan denied 
your request. The Plan says the TMS treatment is not reasonable or necessary at this time. The clinical 
documentation provided and reviewed shows the enrollee with a history of bipolar disorder, current episode 
depressed, severe, without psychotic features. 
 
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 TMS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have a diagnosis of major depressive disorder. As rTMS is considered 
medically necessary only for treatment of adults with a confirmed diagnosis of major depressive disorder that is 
resistant to other treatment, it is not medically necessary for the treatment of an individual with Bipolar 
affective disorder. The requested treatment is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial (90867), 
therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and 
management, per session (90868) and therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; 
subsequent motor threshold re-determination with delivery and management (90869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral nutrition (B4154). 
 
You asked the Plan to pre-approve enteral nutrition. You say that this would help with the members appetite. 
The Plan denied your request. The Plan says this is not a covered item. 
 
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 enteral nutrition (B4154).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you cannot walk from one room to another, and you 
cannot function. The Plan denied your request. The Plan says the requested SNF services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.