Persius/hicric huggingface dataset:
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 go back to your home for home health as 
that would not help you. You have to have constant care and home health would not do that for you. You have 
no home to go back to as you abandoned your apartment since you cannot live by yourself. The Plan denied 
your request. The Plan says this 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 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 skilled nursing facility (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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on August 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee-shin system stance flexion feature represented by 
code L5845. 
 
You asked the Plan to pre-approve code L5845. You say that the records provided support the need for the item 
in dispute to be used along with the approved primary code of L5814. The Plan denied your request. The Plan 
says stance control is included in the approved knee unit represented by code L5814, as indicated in the 
description. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician shall not unbundle services that are 
integral to a more comprehensive procedure. A physician shall not report multiple codes when a single 
comprehensive code describes these services. 
 
We looked at the file and Medicare rules. The records show that the provider requested and received approval 
for coverage of L5814. Code L5845 would be inclusive to code L5814, as the stance phase is included in code 
L5814. Based on this information, we decided that Medicare rules for coverage of code L5845 have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a knee-shin system stance flexion 
feature represented by code L5845.
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 IRF care is medically necessary, and she meets 
the criteria for the IRF care. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 was hospitalized with diastolic congestive heart failure and is now medically stable for discharge from the hospital. The enrollee's functional deficits do not require intensive 
rehabilitation to restore or maintain function. The enrollee does not require frequent physiatry oversight. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program.  There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
members medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) on both shoulders. 
 
You asked the Plan to pre-approve the MRI. You say that you are unable to move your right arm and shoulder. 
The Plan denied your request. The Plan says there was no documentation of prior activity modification, 
physical therapy or the use of ant-inflammatory medications. 
 
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 
MRI on both shoulders is not medically necessary. Our physician reviewer found that the record indicates that 
the enrollee has shoulder pain. The record indicates that plain films demonstrate bilateral osteoarthritis of the 
shoulders. The record does not indicate that a face-to-face encounter with physical examination was performed. 
The requested service is not medically necessary and reasonable for the diagnosis and treatment for the 
enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied. 
 
  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 a magnetic resonance imaging (MRI) on both shoulders.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral cryoablation of posterior nasal nerves (30999). 
 
You asked the Plan to pre-approve the surgical service. You say that the requested service is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested service 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 the surgical service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service for the enrollee's clinical condition compared to standard therapies. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. Therefore, the reviewer found that the requested service 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 the surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bilateral cryoablation of posterior nasal nerves (30999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that a stair lift will help prevent serious injuries. The 
Plan denied your request. The Plan says a stair lift is not primarily 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 requested stair lift 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 stair lift.
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 currently meets full IRF criteria and the 
IRF care is medically necessary. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 chronically deconditioned. The enrollee has limited capacity to respond to intensive rehabilitation. The enrollee does not require frequent physiatry oversight as their chronic 
medical conditions may be managed at an outpatient level. 
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is 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 there is no documentation provided indicating medical necessity for admission to 
a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic tooth #'s 7, 9 and 
11 (D6740) and retainer crown - porcelain/ceramic tooth #'s 8 and 10 (D6245). 
 
You asked the Plan to pre-approve the retainer crown - porcelain/ceramic tooth #'s 7, 9 and 11 (D6740) and 
retainer crown - porcelain/ceramic tooth #'s 8 and 10 (D6245). You say that you are asking for this request be 
re-evaluated since you have the right to have the service covered in full. The Plan denied your request. The 
Plan says the radiographic image sent and the patients dental history, do not comply with the established 
dental clinical criteria. 
 
 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. The Plan covers the retainer 
crown - porcelain/ceramic tooth #'s 7, 9 and 11 (D6740) and retainer crown - porcelain/ceramic tooth #'s 8 and 
10 (D6245) when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the retainer crown - porcelain/ceramic 
tooth #'s 7, 9 and 11 (D6740) and retainer crown - porcelain/ceramic tooth #'s 8 and 10 (D6245). Our reviewer 
says that the documentation provided does not meet the criteria for coverage for a fixed bridge replacing 
missing teeth #'s 8 and 10, with pontics (D6245) using teeth #'s 7, 9 and 11 as abutment retainers (D6740). Our 
physician reviewer found the prognosis of the service is poor due to the lack of periodontal support of the 
abutment retainers. A review of the documentation indicates more than 50% bone loss around the abutment 
retainers. Due to the lack of adequate bone support, the criteria for coverage have not been met for a fixed 
bridge. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the retainer crown - porcelain/ceramic tooth #'s 7, 9 and 11 (D6740) and 
retainer crown - porcelain/ceramic tooth #'s 8 and 10 (D6245) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a retainer crown - porcelain/ceramic tooth #'s 7, 9 and 11 (D6740) and 
retainer crown - porcelain/ceramic tooth #'s 8 and 10 (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections (ESIs) (64483, 64484). 
 
You asked the Plan to pre-approve repeat ESIs. You say that the enrollee needs these. The Plan denied your 
request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the initial injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat ESIs. Our reviewer says that the 
requested repeat ESIs are not medically necessary. Our physician reviewer found the provided documentation 
does not support that the enrollee had at least 50% pain relief for three months. Therefore, the reviewer found 
that the requested ESIs are 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 repeat ESIs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat epidural steroid injections (ESIs) (64483, 64484).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on September 19, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you disagree with the copayment. 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 $325 
copayment for outpatient diagnostic tests/Medicare-covered diagnostic radiology services that are not 
ultrasounds.  
 
You have been asked to pay a $325 copayment for an MRI. However, you are only being asked to pay $280.42 
which is less than the required amount. This item/service falls within the outpatient diagnostic tests/Medicare-
covered diagnostic radiology services that are not ultrasounds benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a magnetic resonance imaging (MRI) provided on September 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from May 19, 2022, to July 4, 2022. 
 
You asked the Plan to pay for SNF care. You say that your medical records show that you did need to be there 
and did need therapy after seeking treatment for your heart. The Plan denied your request. The Plan says this 
was 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 pay for 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 skilled nursing facility (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 pay for SNF care provided from May 19, 2022, to July 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a PCP visit provided on October 7, 2022. 
 
You asked the Plan to waive the deductible for a PCP visit. You say that you should not be responsible for any 
cost sharing for a PCP visit. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to out-of-network PCP services.  
 
The item or service you asked the Plan to waive the deductible for falls within the primary care provider 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $1,000 deductible which applies to out-of-network PCP services. This cost sharing is a contractual 
obligation that had not been met at the time the claim was processed. Therefore, we decided that the Plan does 
not have to waive the deductible for a PCP visit provided on October 7, 2022.