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

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee does not require the intensity of services provided at an 
IRF. Specifically, the enrollee is not shown to require, or currently to be able to tolerate, fifteen hours per week 
of rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a lower level 
of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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. You say that the enrollee requires prolonged acute 
care needs to address his complicated comorbidities. The Plan denied your request. The Plan says there are no 
complicated wounds or medications which cannot be given in the current location. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute hospital for status epilepticus. His hospitalization 
was complicated by hypotension, pancreatitis, pneumonia, and liver failure. He is receiving appropriate care at 
the present acute care hospital. He does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the erupted tooth extraction rendered on October 19, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the charges. The Plan denied your 
request. The Plan says the claim was processed correctly. 
 
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 covers optional 
supplemental dental services with a $100 deductible per calendar year and a 50% coinsurance for tooth 
extractions after the annual deductible is met.  
 
We looked at the file and the Plan's rules. The file shows that you had a tooth extraction on October 19, 2021. 
The Plan applied $92.50 towards your $100 deductible for these services. At this time, the $100 annual 
deductible had been met. Given that the deductible charge did not cover the entire cost of the services, you have been asked to pay a 50% coinsurance of the remaining amount for these services. The total amount you have been asked to pay for these 
services is $425. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the 
optional supplemental dental benefit with the Plan. 
 
Based on this information, we decided that the Plan's rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the erupted tooth extraction rendered on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services (CPT code(s): 99203 and 99213) to 
be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says a network provider can care for the enrollee's medical problem. 
 
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 
the office services (CPT code(s): 99203 and 99213) to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a polysomnography (95810). 
 
You asked the Plan to pre-approve a polysomnography. You say that there is no sleep study scored at 4%. You 
also say that the enrollee failed a home sleep study which is why you need an in-lab titration. The Plan denied 
your request. The Plan says that the enrollee already had a asleep study completed where it was determined 
they had OSA, and they are currently using a Continuous Positive Airway Pressure device (CPAP) therapy for 
treatment. The Plan also says that a new sleep study is not needed in order for the enrollee to obtain new 
continuous positive airway pressure supplies. 
 
The Plan follows Medicare rules. Medicare rules say that sleep testing is covered for evaluation of suspected 
sleep apnea in patients with signs and symptoms of the condition. 
 
 
  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 polysomnography. Our reviewer says 
that the enrollee meets the coverage criteria for a polysomnography. Our physician reviewer found in this case 
the enrollee was noted to have a prior diagnosis of obstructive sleep apnea (OSA) based on prior sleep testing. 
However, that testing was not done/scored using Medicare's definition of a hypopnea (versus the American 
Academy of Sleep Medicine's scoring rules). Our reviewer found that the applicable National Coverage 
Determination (NCD) otherwise states that sleep testing is covered for evaluation of suspected sleep apnea in 
patients with signs and symptoms of the condition. The records provided for review do support that the 
member has symptoms of OSA by history. Our physician reviewer also found that given that testing is being 
done to (re)-establish a diagnosis of OSA, it would appear that the requirements of the NCD are met. 
 
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 polysomnography have been met. Therefore, we decided that the Plan has to 
pre-approve a polysomnography (95810).  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan says you would have difficulty tolerating 3 hours of 
therapy a day. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for surgical management of bowel obstruction and respiratory 
failure. Your medical problems are stable. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The complexity 
of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on December 20, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that you would like reconsideration because 
you were told this was a covered service. The Plan denied your request. The Plan says acupuncture is only 
covered for the treatment of chronic low back pain. 
 
 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, [ADJUDICATOR ENTER CASE SPECIFICS]. 
Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on December 
20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay further for the dental services rendered on October 6, 2021. 
 
You asked the Plan to pay further for these services. You say that you were told you would still get some of the 
portion of the bill paid. The Plan denied your request. The Plan says the claim was processed correctly. 
 
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 contract says that 
there is a $100 calendar year deductible for optional supplemental dental benefits.  
 
We looked at the file and the Plan's rules. The file shows that you received dental services on October 6, 2021. 
The Plan applied a total of $96.80 to your $100 deductible for these services. Given that the provider is not a 
network provider with the Plan, they may balance bill you for the remainder of the services. Based on this 
information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay further for the dental services rendered on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there are in-network providers within a reasonable distance from your 
location that can provide this service or item. 
 
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 
the office visit to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device and accessory. 
 
You asked the Plan to pre-approve a power mobility device. You say that the current scooter that you have can 
only go 8 blocks before the battery dies. The Plan denied your request. The Plan says this device is not covered 
according to Medicare rules. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Specifically, you are requesting a device that can 
travel additional blocks indicating that this is to be used outside the home. Although this item may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan 
does not have to pre-approve a power mobility device and accessory.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical equipment provided on February 9, 2021 to June 
14, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical equipment. You say that you would like to be reimbursed for this 
equipment. The Plan denied your request. The Plan says there was no emergent need for these items purchased 
from an OON provider and in-network options were available. 
 
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 the medical 
equipment provided on February 9, 2021 to June 14, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan from the skull base to the mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET-CT scan of skull base to mid-thigh. You say that the requested 
service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 
for the requested service have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare continues to nationally non-cover FDG PET 
imaging for initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the 
prostate. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PET-CT scan of skull base to mid-thigh have not been met. Specifically, the request is for FDG 
PET imaging for initial anti-tumor treatment strategy for a prostate cancer diagnosis, which is not a covered 
benefit.  
 
 
 
 
 
 Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan from the skull base to the mid-thigh (78815).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve the additional OT visits. You say that the enrollee has a brain tumor and is 
getting better with the potential for more. The Plan denied your request. The Plan says additional OT visits are 
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 additional OT visits. 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 requested therapy is not generally accepted as specific 
and effective therapy for the patient's condition. Our reviewer found that the records do not demonstrate that 
the unique skills of a professional therapist are required to provide treatment safely and effectively, that the 
services can be safely and effectively performed only by a therapist, or for physical therapy and occupational 
therapy, by or under the supervision of a therapist. Our physician reviewer also found that the requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist required to establish, design and/or deliver a program to maintain the patient's current 
condition or to prevent or slow further deterioration is not 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 additional OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional occupational therapy (OT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the lift chair monthly rental for dates of 
service September 14, 2021, and October 14, 2021. 
 
You asked the Plan to provide reimbursement for the lift chair rental. You say that you broke your ankle and 
needed a lift chair while you recovered. You rented this from the only provider of this in your area. The Plan 
denied your request. The Plan says this cannot be covered because the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
Though the Plan's denial was due to you using a non-Medicare provider, we find that coverage criteria are not 
met regardless of the Medicare status of the supplier you used. This was obtained due to a broken ankle, and 
there is no documentation of severe knee/hip arthritis or any neuromuscular disease.  This means you do not have a condition for which Medicare covers a lift chair. Therefore, we decided that the 
Plan does not have to provide reimbursement for the lift chair monthly rental for dates of service September 14, 
2021, and October 14, 2021.
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 need SNF care to get stronger with therapy to 
get back to being independent again. The Plan denied your request. The Plan says the stay is not medically 
necessary based on SNF criteria. 
 
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 there is no documentation that you require 
skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are 
not required to safely and effectively provide medically necessary and reasonable treatment. Records do not 
document the need for intravenous medications, new tube feeding, or ostomy care or daily complex wound 
care. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified 
therapist are required to safely and effectively provide medically necessary and reasonable treatment. There is 
no documentation that daily skilled services are required. Provided records do not recommend daily therapy; an 
occupational therapy note of April 25, 2022, recommends treatment two (2) times per week and a physical 
therapy note of April 22, 2022, recommends home health or outpatient physical therapy. There is no 
documentation that you require the services on an inpatient basis, only in a SNF setting. Provided records do 
not document services in the home with home health care or in a long-term care facility on a part time basis are 
not appropriate in this case. 
 
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.