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. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee can be treated at the current hospital. 
 
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 the medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition to lower extremity prosthesis, user 
adjustable heel height (L5990). 
 
You asked the Plan to pre-approve the addition to lower extremity prosthesis. You say that you would like to 
request an appeal based on medical necessity. The Plan denied your request. The Plan says the alignable system 
is not a necessary part of the replacement socket. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the addition to lower extremity prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve the addition to lower extremity prosthesis, user adjustable heel height (L5990).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain/ceramic crown (D2740) for tooth #30. 
 
You asked the Plan to pre-approve the crown. You say that you were told this crown is denied because it can 
only be performed once per tooth every five years, but you have not had this procedure within five years. The 
Plan denied your request. The Plan says that you previously had a crown provided for this tooth in December 
2021. Crowns are only covered once per tooth every five years. Therefore, this request is denied. 
 
The Plan must follow Medicare rules. 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 one crown per tooth every five years. The rules also say that Medicare health plans must 
make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to 
deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan states that your request is denied because you previously 
had a crown provided for tooth #30 in December 2021. No documentation was provided in the case file to 
support that you have ever had a crown on tooth #30, or that a crown for this tooth was recently covered by the 
Plan. Therefore, we decided that the Plan has to pre-approve a porcelain/ceramic crown (D2740) for tooth #30.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 23, 24, 25, and 26, core 
buildups, including any pins when required (D2950) for tooth #'s 23, 24, 25, and 26, and endodontic therapies 
(D3310) for tooth #'s 23 and 26. 
 
You asked the Plan to pre-approve the crowns, core buildups, and endodontic therapies. You say that these 
services are not cosmetic. You also say that your teeth may get infected if they are not treated. The Plan denied 
your request. The Plan says for these services to be approved, once the decay is removed you must have 
enough healthy tooth to support these services. The Plan also says that the x-rays show that there is a lot of 
decay on these teeth and there is not enough healthy tooth that will support these services. 
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 the crowns, 
core buildups, and endodontic therapies 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 crowns, core buildups, and 
endodontic therapies. Our reviewer says that the documentation provided does not meet the criteria for 
coverage for the services indicated. Our physician reviewer found due to the poor quality of the x-rays, a 
determination of the amount of breakdown in the indicated teeth could not be made. Our reviewer also found 
that diagnostic x-rays are required to determine if the criteria for coverage has been met. 
 
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 crowns, core buildups, and endodontic therapies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 23, 24, 25, and 
26, core buildups, including any pins when required (D2950) for tooth #'s 23, 24, 25, and 26, and endodontic 
therapies (D3310) for tooth #'s 23 and 26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit kit and push handles for the enrollee. 
 
You asked the Plan to pre-approve a transit kit and push handles. You say that this is medically necessary. The 
Plan denied your request. The Plan says that these items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal 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 transit kit and push handles for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy (D7286) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve an incisional biopsy. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says D7286 is not a covered benefit. 
 
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 an 
incisional biopsy (D7286) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950) and gingival irrigation (D4921). 
 
You asked the Plan to pre-approve the core buildup, gingival irrigation, crown, and periodontal scaling and root 
planing. You say that you believe these services should be covered. The Plan denied your request. The Plan 
says these services are not covered expenses under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup, including any pins when required (D2950) and gingival irrigation (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the denture. You say that this service is necessary. The Plan denied your 
request. The Plan says dentures are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and an 
implant/abutment supported removable denture (D6112). 
 
You asked the Plan to pre-approve the dentures. You say that you have $1,500 for dental care under your plan, 
and you do not understand why your requests are denied. The Plan denied your request. The Plan says these 
services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial upper denture (D5213) and an implant/abutment supported removable denture (D6112).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided October 25, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that this service was necessary to evaluate dental 
discomfort. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
service. 
 
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 limited 
oral exam once per plan year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on January 4, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation - problem focused (D0140) provided October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dentures. You say that these dentures are necessary. The Plan denied 
your request. The Plan says dentures are not covered by your dental benefit. 
 
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 states that 
prosthodontic treatment including, but not limited to bridges, implants, dentures and partial dentures are not 
covered by this benefit. 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 a 
partial upper denture (D5213) and partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair 
 
You asked the Plan to pre-approve a power wheelchair. You say that this is medically necessary. The Plan 
denied your request. The Plan says durable medical equipment is not covered when provided in a skilled 
nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair is being requested for use in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system (L5981) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the member's physician does not document activities in the medical record that 
are consistent with K3 ambulatory function. 
 
The Plan must follow Medicare rules. Medicare rules say that a flex-walk system or equal is covered for 
beneficiaries whose functional level is 3 or above. 
 
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 requested services are not considered medically reasonable and necessary in this case. There is inadequate 
documentation to support that the enrollee is a K3 level ambulator to support medical necessity of the flex-walk 
system at issue in this case as required by Medicare criteria.  Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a flex-walk system (L5981) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planning (D4341 x2), bone 
replacement grafts (D7953 x7), gingival irrigation (D4921 x2), add clasp to existing partial denture (D5660 
x3), and other drugs and/or medicaments (D9630 x3). 
 
You asked the Plan to pre-approve periodontal scaling and root planning, bone replacement grafts, gingival 
irrigation, add clasp to existing partial denture, and other drugs and/or medicaments. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says the services at issue are not 
covered 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, 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 
periodontal scaling and root planning (D4341 x2), bone replacement grafts (D7953 x7), gingival irrigation 
(D4921 x2), add clasp to existing partial denture (D5660 x3), and other drugs and/or medicaments (D9630 x3).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for individual psychotherapy services (90832) provided July 20, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says that the services are not 
supported without the required documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have been met. Specifically, the record shows that the enrollee was referred 
to this provider by their attending/primary physician. Therefore, we decided that the Plan has to pay for 
individual psychotherapy services (90832) provided July 20, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments - includes placement 
(D6057) and abutment supported porcelain fused to metal crowns (high noble metal) (D6059) and abutment 
supported retainer for porcelain fused to high noble metal (D6069). 
 
You asked the Plan to pre-approve the custom fabricated abutments, abutment supported crowns and abutment 
supported retainer. You say that you really need these services. The Plan denied your request. The Plan says 
these services are not covered under your 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, 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 custom fabricated abutments - includes placement (D6057) and abutment supported porcelain fused to metal crowns (high noble metal) (D6059) and abutment supported retainer for porcelain fused to high noble metal (D6069).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says this request does 
not meet the Plan's Part B step therapy criteria for the requested drug. 
 
  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that 
Feraheme is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. 
Our reviewer also found that the record does not indicate that the enrollee has a contraindication to, or would 
have an adverse effect from the Plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services 
you and/or your provider are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 77-year-old male with End-Stage Renal Disease (ESRD) who 
was admitted to the acute care hospital with infected hip wound/osteomyelitis following recent right hip open 
reduction and internal fixation (ORIF) procedure requiring surgical debridement and antibiotics and 
complicated by COVID-19 positive, pneumonia, and acute respiratory failure requiring respiratory support, 
hemodialysis, ongoing intravenous antibiotics, and wound care. Recent notes describe the enrollee having the 
wound closed recently, tolerating physical therapy and occupational therapy, tolerating hemodialysis 3 days a 
week again (baseline), and is now tolerating room air with good oxygenation. The enrollee appears to be improving and should only require short-term additional acute care services that can be safely administered at 
the current facility for the time being until a lower level of care is appropriate. The enrollee does not require 
services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Admission to 
LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care 
may be considered when treatment has completed.  
 
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.