Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that you can safely 
receive the services you need in other settings. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that clinicals provide evidence that you require skilled nursing due to worsening of wound. You require 
intense rehabilitation by speech therapy for new cognitive impairments and physical and occupational therapy 
for worsened mobility impairments. Due to your documented medical history of stroke and new impairments, 
you would be expected to require an interdisciplinary team led by a rehabilitation physician. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has been working diligently with 
inpatient therapy and will continue to do so in an IRF. The Plan denied your request. The Plan says IRF is not 
medically necessary and a skilled nursing facility is recommended for the enrollee's continued care needs. 
 
The Plan must follow Medicare rules. The rules say that an 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 while the enrollee may benefit from physical therapy (PT), and occupational 
(OT), his rehab needs can be addressed at a low intensity alternate setting such as in a skilled nursing facility (SNF) or in-home with home health services. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from September 8, 2021, to September 24, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you should not be responsible for the 
$2,024 copayment because the hospital is a network provider. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount.  
 
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 $0 
copayment for days 1-20 for an in-network skilled nursing facility stay. The contract also says that there is a $184 copayment for days 21-57. The contract says a benefit period begins on the first day you go to a 
Medicare-covered a skilled nursing facility and the benefit period ends when you have not been an inpatient at 
any SNF for 60 days in a row. 
 
The record shows the services you received by an out-of-network provider but were covered at the in-network 
benefit rate. The EOC states a new benefit period starts when you have not been an inpatient for 60 days in a 
row. You used 15 days of the 20-day allowance from July 1, 2021, to July 16, 2021, and the remaining five 
days from September 8, 2021, to September 12, 2021. You have been asked to pay a total of $2,024, which is a 
$184 copayment per day for the remaining 11 days from September 13, 2021, to September 24, 2021 ($184 
copayment x 11 days = $2,024). 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 skilled nursing facility 
(SNF) stay provided from September 8, 2021, to September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's current medical conditions and 
treatment along with his past medical history supports the need for an IRF admission. The Plan denied your 
request. The Plan says IRF is not medically necessary and the enrollee's needs can be met at a lower level of 
care. 
 
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 while the enrollee may benefit from physical therapy (PT), and occupational therapy (OT), his rehab needs can be addressed at a low intensity alternate setting such as in a skilled nursing 
facility (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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat cervical epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the repeat ESI. You say that this should be covered. The Plan denied your 
request. The Plan says a repeat ESI is not reasonable and necessary at this time. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of a repeat ESI is allowed when the prior 
injection provided at least 50% 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 the repeat ESI. Our reviewer says that 
the requested ESI is not currently considered reasonable and necessary. Our physician reviewer found the 
enrollee is a 65-year-old female with a history of bilateral shoulder pain and neck pain with cervical 
radiculopathy. In this case, the documentation shows that the 1st cervical ESI was done on 1/27/2022. The 
second was requested just over one month later. This is not considered reasonable and necessary based on the 
guidelines as three months of pain relief were not achieved. 
 
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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat cervical epidural steroid injection (ESI).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that you have to be cleaned every day by a certified 
nurse and have three abscesses that need to be cleaned and drained daily. You say that you are partially 
disabled and need help or are subjected to fall. The Plan denied your request. The Plan says placement in a 
skilled nursing facility is not necessary at this time. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that based on the medical records 
provided there is no documentation that you require the services on an inpatient basis, only in a skilled nursing 
facility setting. The latest records available support that home health services have been arranged to provide 
care for you in the home. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Wound Care services provided on December 20, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Wound Care services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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 Wound Care services provided on December 20, 
2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF will provide the enrollee with the necessary 
rehabilitation and other services. The Plan denied your request. The Plan says based on Medicare guidelines, 
the requested SNF services do not meet the requirements for approval. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that 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 skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance for therapeutic continuous glucose 
monitor (CGM), includes all supplies and accessories(K0553) and a receiver/monitor for use with a CGM 
system (K0554). 
 
You asked the Plan to pre-approve a supply allowance and a receiver/monitor for a CGM system. You say that 
you have been waiting 5 weeks for this glucose monitor and you have been a diabetic for 20 years. The Plan 
denied your request. The Plan says you do not meet prior authorization criteria. 
 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 documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a supply allowance and a receiver/monitor for a CGM system have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a supply allowance for 
therapeutic continuous glucose monitor (CGM), includes all supplies and accessories(K0553) and a 
receiver/monitor for use with a CGM system (K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve a crown. You say that you would like to go to a trusted out-of-network. You 
say that an in-network provider caused you an injury. The Plan denied your request. The Plan says there are in-
network providers available for these 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. The Plan covers a crown when 
the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2751) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on December 10, 2021. 
 
You asked the Plan to pay for the dental service. You say that no bone replacement graft was done. You say 
that you only received an extraction. The Plan denied your request. The Plan says bone replacement graft is not 
listed as a covered service. The Plan also says that the dental records indicate that this was not a billing error. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation (D7953) provided on December 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the he enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection (CPT code 64484-50). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says medical studies do not show this works better when done for more than one level. 
 
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 services. Our physician reviewer 
found according to the coverage criteria, Medicare rules say that no more than two transforaminal epidural 
injections may be performed at a single setting (e.g. single level bilaterally or two levels unilaterally). The 
review has determined that the requested bilateral TFESIs at the second nerve root level 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 the services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve epidural steroid injection (CPT code 64484-50).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010) for multiple teeth, custom 
abutment (D6057), abutment supported porcelain crown (D6059), bone replacement grafts for ridge 
preservation (D7953) to be provided by a participating provider. 
 
You asked the Plan to pre-approve implant placement, custom abutment, abutment supported porcelain crown, 
bone replacement grafts for ridge preservation. You say that you are unable to chew, and you need to have 
these implants. The Plan denied your request. The Plan says the requested dental 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant placement (D6010) for multiple teeth, custom abutment (D6057), abutment supported porcelain crown 
(D6059), bone replacement grafts for ridge preservation (D7953) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the out of network liability for the oral exam (D0120), 
prophylaxis (D1110), bitewing x-rays (D0274), fluoride varnish (D1206), and fillings (D2391, D2332, D2331) 
provided from September 21, 2021, to November 23, 2021. 
 
You asked the Plan to waive the out of network liability for the dental services. You say that the enrollee was 
initially given a cost analysis indicating the dental charges would be covered. You say that the enrollee started 
receiving bills. You also say that you feel the nitrous oxide should be covered and the other charges should be waived. 
The Plan denied your request. The Plan says the out of network member liability was applied correctly 
per the enrollee's plan benefits. 
 
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, out of network dentists may bill you 
for any amount greater than what the plan pays the provider. Therefore, we decided that the Plan does not have 
to waive the out of network liability for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), 
fluoride varnish (D1206), and fillings (D2391, D2332, D2331) provided from September 21, 2021, to 
November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation and tooth extraction to be provided by an 
Oral Surgeon. 
 
You asked the Plan to pre-approve dental services. You say that you need these extractions done by the oral 
surgeon because of the medication you are taking. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the services of an oral surgeon are not covered by the Plan's 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit when performed by an oral surgeon. Therefore, we decided that the 
Plan does not have to pre-approve an evaluation and tooth extraction to be provided by an Oral Surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies rendered on November 25, 2021. 
 
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. 
 
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 S1015 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S1015 is not valid for Medicare purposes. Code A4930 has a status indicator of X and is statutorily 
excluded. 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 pay for the supplies rendered on November 25, 2021.