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. The Plan denied your request. The Plan says you do 
not meet the criteria for coverage for an LTACH admission and stay. 
 
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 there is no evidence that you require services that are not locally available. As 
LTACHs and Acute Care Hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring you to the LTACH. Our reviewer found that you can remain at the current ACH until 
such time no acute services are required. Our physician reviewer also found that you then can be 
transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
 
  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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot/cold pack therapy provided on December 6, 2021, 
billed with code 97010. 
You asked the Plan to pay for the hot/cold pack therapy. You say that this claim should be paid. The Plan 
denied your request. The Plan says payment was made for this claim, but separate payment is not allowed for 
code 97010. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the hot/cold pack therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
the hot/cold pack therapy provided on December 6, 2021, billed with code 97010.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 is medically stable and does not need Physical Medicine and 
Rehabilitation (PM&R) physician close supervision three (3) times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. No rehabilitation nursing 
needs identified or documented in the record. At the current functional level, the enrollee does not need intensive therapies, consisting of at least three (3) hours of therapy per day at least five (5) days per week with 
multidisciplinary approach to daily therapy in an IRF. The enrollee needs routine physical therapy (PT), and 
occupational therapy (OT) and that can be safely provided in a skilled nursing facility (SNF). IRF admission is 
not medically necessary based on medical stability and lack of medical complexity, and lack of rehabilitation 
nursing needs. Document does not support the necessity for admission to an IRF. While the enrollee may 
benefit from PT, and OT, the enrollee's rehabilitation can be safely provided at a lower intensity and alternate 
setting such as in an SNF. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that these services are 
necessary to get the enrollee to dialysis appointments. The Plan denied your request. The Plan says that the 
beneficiary has exhausted this benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
with falls and weakness. He received oral medications and had stable vital signs. He received physical and 
occupational therapy in the hospital and needs contact guard assist with functional mobility, including gait to 
200 feet with a rolling walker. He needs varied assist with activities of daily living. He has no skilled nursing 
needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, 
the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary denture you received on March 9, 2021. 
 
You asked the Plan to pay for the maxillary denture. You say that this bill should have been sent to the Plan in 
2020. The Plan denied your request. The Plan says you did not physically receive this denture from the dentist 
until March of 2021, so the 2021 rules apply.  Maxillary dentures are not covered in 2021. 
 
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, dentures are not covered under your 
2021 benefits.  This claim appropriately applied to your 2021 benefits because you were not provided with the 
denture until March of 2021. Therefore, we decided that the Plan does not have to pay for the maxillary denture 
you received on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day sensor (CPT code K0553). 
 
You asked the Plan to pre-approve the sensor. You say that the reader is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The records do not show that you are on insulin, either via insulin 
injections or an insulin pump. Based on this information, we decided that Medicare rules for coverage of the 
sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 
14-day sensor (CPT code K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services and nail debridement 
provided on December 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility services and nail debridement. You say that the patient is 
a resident in a nursing home and has an authorization on file for all care at the facility including consultations. 
The Plan denied your request. The Plan says a prior authorization was never requested by the out-of-network 
provider or member, and the rendering provider is not participating with the Plan. 
 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 skilled nursing facility services and nail 
debridement provided on December 15, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor imaging, positron emission tomography (PET); 
whole body (78813) to be provided by an out-of-network (OON) provider. 
 You asked the Plan to pre-approve the diagnostic service. You say that that you would like to appeal because 
the CT chest showed solitary lung nodule suspicious for malignancy. The Plan denied your request. The Plan 
says the information provided does not show that the enrollee has a cancer that is biopsy proven or strongly 
suspected based on other diagnostic testing. 
 
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 
tumor imaging, positron emission tomography (PET); whole body (78813) to be provided by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
glioblastoma. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for 
the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for 
the use of the requested drug in the enrollee's clinical situation. The services are therefore not safe and effective 
or reasonable and medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Zolpidem tablet. 
 
You asked the Plan to pre-approve Zolpidem. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Zolpidem 
tablet.  
 
Benefits for Zolpidem may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dentures provided on November 24, 2021, from an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON dentures. You say that you have a $1000 benefit for dental services 
which does not say anything about only being in-network. The Plan denied your request. The Plan says you 
have a Plan that does not include OON benefits. This was correctly denied. 
 
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, this coverage does not apply to OON 
services. Therefore, we decided that the Plan does not have to pay for the dentures provided on November 24, 
2021, from an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable ambulance supplies. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
code is not a Medicare covered code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code A0382 is basic life support routine disposable supplies. 
We find that supplies are included in the base rate for the approved services.  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 disposable ambulance supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance rendered on January 13, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance rendered on January 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen for 
the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services must be reasonable and necessary for the diagnosis or treatment of the 
specific patient involved. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has 
reported Barrett's esophagus without dysplasia, personal hx of breast CA s/p mastectomy and recurrence treated 
with lumpectomy, chemotherapy, and radiation therapy. She has a positive ATM gene. This MRI was 
requested for cancer screening. She reported rare heartburn and no significant change in symptoms. The 
physical exam showed a non-tender abdomen, without masses and organomegaly. The colonoscopy from 2020 
revealed one tubular adenomatous polyp that was resected and 5 hyperplastic colonic polyps. The 
esophagastroduodenoscopy from 2020 showed no dysplasia. There is no currently recommended screening for 
pancreatic cancer supported by current guidelines and there was no recent change in symptoms or objective 
physical findings to justify advanced imaging of the abdomen. Therefore, this request for MRI abdomen will be 
considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the abdomen for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that a couple weeks of skilled rehab and 
strengthening would be very beneficial. The Plan denied your request. The Plan says they have covered over 
100 days for you in the SNF. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period starting from October 2020. 
The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required 
to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new 
benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days 
in a row. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (code D4341) you received on December 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dental office said that this was all covered 
and the copays would be worked out in a way you could afford them. The Plan denied your request. The Plan 
says you have exhausted your dental allowance for the year and that is why these dental services were not paid 
in full. 
 
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's contract says that 
you have dental coverage coverage up to a $1000 combined allowance every year. You are responsible for any 
amount over the allowance.  You have exhausted this $1000 benefit, which is why this claim was only partially 
paid.  The amount not paid on this claim is the amount remaining after your allowance was exhausted. 
Therefore, we decided that the Plan does not have to pay for dental services (code D4341) you received on 
December 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rhopressa. 
 
You asked the Plan to pre-approve Rhopressa. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rhopressa.  
 
Benefits for Rhopressa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.