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

 
We decided that the Plan does not have to pre-approve the continued inpatient hospital care from March 18, 
2022, forward. 
 
You asked the Plan to pre-approve the continued inpatient hospital care. You say that the enrollee needs a 
continued stay until she can find a dialysis center that will accept her for outpatient dialysis with a trach in 
place. The Plan denied your request. The Plan says the continued inpatient hospital stay 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 continued inpatient hospital care. 
Our reviewer says that the continued inpatient hospital care from March 18, 2022, forward, is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the documentation does not 
support that the continued inpatient stay from March 18, 2022, forward was medically reasonable and 
necessary, as the enrollee was stable and awaiting placement. 
 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 continued inpatient hospital care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the continued inpatient hospital care from March 18, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent (64633 and 64634). 
 
You asked the Plan to pre-approve the destruction by neurolytic agent (64633 and 64634). The Plan denied 
your request. The Plan says the criteria for coverage has not been met as only one diagnostic cervical facet joint 
injection procedure has been performed.  
 
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 destruction by neurolytic agent 
(64633 and 64634). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee has cervical neck pain 
and has not undergone two successful diagnostic injections. The elements of the coverage criteria are not 
satisfied, and the requested service is not recommended. 
 
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 destruction by neurolytic agent (64633 and 64634) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the destruction by neurolytic agent (64633 
and 64634).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for this device is correct, because a ventilator is not covered 
by Medicare for this purpose and a bi-level positive airway pressure (BiPAP) device with average volume 
assured pressure support (AVAPS) mode would meet all of the requested needs. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators are not covered by Medicare when 
used to provide positive airway pressure (PAP) therapy, regardless of the underlying medical condition.  
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. A ventilator is not covered by Medicare for the requested purpose. 
The Plan says that a BiPAP device with AVAPS mode could meet your needs instead. Please contact the Plan 
regarding coverage of your treatment options. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
portable ventilator.
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 denied your request. The Plan says the enrollee does not 
require close supervision by a rehabilitation physician. 
 
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 the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Her 
medical problems are stable. She does not require treatment by multiple therapies in an intensive rehabilitation 
therapy program. While she has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. 
 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 waive the copayment for an office visit provided on 
October 13, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was a follow up appointment 
for the cataract surgery that you had in June and should be covered. The Plan denied your request. The Plan 
says the service provided on October 13, 2021 occurred beyond the 90 day follow up period and does not 
qualify as a follow up office visit. 
 
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 $20 
copayment for Physician/Practitioner services, including doctors office visits, medical care or surgery services 
in a Specialty Physicians office.  You have been asked to pay a $20 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctors office visits, medical care or surgery services in a Specialty 
Physicians office 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 an office visit 
provided on October 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 1, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation shows the chest x-ray was performed to confirm the position of the line 
placement and absence of pneumothorax and is not separately reportable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on November 1, 2021.
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 an admission to an IRF is medically necessary at this 
time. The Plan denied your request. The Plan says an admission to an IRF 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 there is not a reasonable expectation that the member will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and unspecified 
preventive service (D1999) provided on November 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that your previous dentist dropped your insurance. 
You say that you were not aware that you had to notify your insurance. You also say that an exception should 
be made since it was not your fault you had to find a new dentist. The Plan denied your request. The Plan says 
the claim processed correctly. 
 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 and comprehensive oral evaluation is 
listed as covered, the frequency limit of 1 every 3 years has been exceeded. The record shows that the Plan paid 
for a comprehensive oral evaluation that you received on February 11, 2019. Additionally, unspecified 
preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150) and unspecified preventive service (D1999) 
provided on November 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee's pain is disabling, and 
they have failed non-operative treatment. You say that the evidence supports the use of the Intracept procedure 
as the primary treatment for low back pain and the denial should be overturned. The Plan denied your request. 
The Plan says the Intracept procedure is considered unproven, and more research is needed to show safety and 
efficacy of the procedure. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental and more research is needed.  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial lower denture (D5214) provided on October 20, 
2021. 
 
You asked the Plan to pay for the dental item. You say that you were not aware that your dentist was out of 
network. You say that you are on a fixed income. You also say that to pay for this out of pocket would impose 
undue financial hardship. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 and lower partial denture is listed as 
covered, there is a 100% coinsurance when you receive this service out of network. Therefore, we decided that 
the Plan does not have to pay for the partial lower denture (D5214) provided on October 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from May 24, 2021, through  
June 22, 2021. 
 
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says there is no Medicare 
benefit or health Plan added benefit for custodial care. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for SNF services 
provided from May 24, 2021, through June 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the enrollee has 
suffered from this condition since 2002 and has failed 12 months of conservative approaches to treatment. You 
say that this treatment is considered safe and effective and should be approved. The Plan denied your request. 
The Plan says Medicare does not cover unproven and not medically necessary procedures. 
 
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 insertion of stabilization device 
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee has chronic low back pain, lumbar spinal 
stenosis with neurogenic claudication and a body mass index of 48. The Food and Drug Administration states 
that the requested procedure is contraindicated in an individual with a body mass index of greater than 40. 
Therefore, the elements of the coverage criteria are not satisfied, and the requested service cannot be 
recommended. 
  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 insertion of stabilization device (22869) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen tank (E1392). 
 
You asked the Plan to pre-approve a portable oxygen tank. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the member currently has the standard item that meets her medical 
needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a homefill system using D-tanks and a stationary concentrator. This item serves 
the same purpose as a portable oxygen tank. Therefore, we decided that the Plan does not have to pre-approve a 
portable oxygen tank (E1392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a lack of sufficient high-quality evidence supporting the use of this device. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis 
with neurogenic claudication. The record indicates that the enrollee has significant multi-level disease 
including severe central canal stenosis at L4-L5, the level requested for treatment. 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 reader. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 reader (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that this should be covered. The Plan denied 
your request. The Plan says this has not been shown to be medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a crutch substitute (E0118). have been 
met. Specifically, no medical records besides the original prescription slip have been submitted. Without this 
information, the medical necessity of the requested item cannot be determined. Therefore, we decided that the 
Plan does not have to pre-approve a crutch substitute (E0118).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 22, 2021, to 
February 19, 2021. 
 
You asked the Plan to pay for the home health services. You say that this claim should be paid in full. The Plan 
denied your request. The Plan says the initial Request for Anticipated Payments (RAP) claim within 5 
calendar days from the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the file shows that the initial Request for 
Anticipated Payments (RAP) claim within 5 calendar days from the start of care. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from January 22, 2021, to February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0814). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the member needs an outside mode of 
transportation. The Plan denied your request. The Plan says the member does not have a mobility limitation 
which significantly impairs her ability to participate in one or more MRADLs in the home and she has sufficient strength to power a manual wheelchair. Also, the DME is intended to be used primarily outside, and 
per Medicare, DME is supposed to be used primarily in the home. 
 
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. 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 wheelchair (K0814).