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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is medically stable 
and does not need a physical medicine and rehabilitation physician's close supervision 3 times per week (at a 
minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or documented. The enrollee does not need 3 hours a day x 5 days a week of 
therapies with multidisciplinary approach in an IRF. The document does not support the medical necessity due 
to lack of medical complexity and nursing needs, for admission to an IRF. While the enrollee would benefit 
from physical therapy and occupational therapy, the enrollee's rehab needs can be safely provided in an 
alternate and lower intensity setting such as in a 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH services. The Plan 
denied your request. The Plan says rules for LTACH care have not been met. 
 
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 you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has had very complicated 
and prolonged hospitalizations that have included extensive treatment for spinal abscess with drain placement 
that has included surgical interventions. The Plan denied your request. The Plan says the enrollee's records do 
not show that they need continued treatments and care that can only be given in a hospital setting. 
 
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 enrollee was admitted to the acute care hospital with intraspinal abscess and 
bacteremia at a spinal surgery site requiring oxygen supplementation, surgical intervention including removal 
of hardware, wound care, drain placement, and intravenous antibiotics. The course was complicated by anemia 
requiring transfusions and atrial fibrillation with bradycardia requiring atropine as needed. Recent notes 
describe the enrollee as responding to current treatment, tolerating oral diet, hemodynamically stable, but 
requiring physical therapy.  The enrollee is receiving appropriate care at the present setting. The enrollee does not require services at the 
LTACH that are not available at the facility where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne genetic testing provided on February 15, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that FANCC genetic 
testing is not covered. 
 
The Plan must follow Medicare rules. The rules 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. The Plan argues that per Local Coverage Article (LCA) A53628, FANCC 
genetic testing is not a covered benefit. However, the FoundationOne CDx panel is an FDA-approved test, 
which means this testing is covered per NCD 90.2. As LCA A53628 is superseded by NCD 90.2, the Plan has 
not provided documentation supporting its denial. Therefore, we decided that the Plan has to pay for the 
FoundationOne genetic testing provided on February 15, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that your doctor ordered the portable oxygen 
concentrator and it's currently on back order. The Plan denied your request. The Plan says the services are not 
covered. 
 
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 home oxygen system with portable tanks. The current equipment serves the 
same purpose as the requested portable oxygen concentrator. Therefore, we decided that the Plan does not have 
to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x4) provided on 
April 20, 2022. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that you were advised that some of 
the cost would be paid by the Plan. 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 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 pay for 
periodontal scaling and root planing (D4341 x4) provided on April 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the elevating legs rests (E1012) and electronic 
connection (E2311). 
 You asked the Plan to pre-approve the elevating legs rests and electronic connection. You say that this 
equipment is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
criteria for coverage of these power wheelchair parts have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the electronic connection and elevating leg rests are 
subject to the criteria listed 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 the elevating legs rests and electronic 
connection. Our reviewer says that this equipment is not medically reasonable and necessary. Our physician 
reviewer found that the documentation does not reveal that the enrollee has leg edema, contractures in the 
lower extremities, inability to flex the knees, or requires this to be used with the approved power tilt feature.  
The medical progress note documentation does not reveal evidence of leg contractures, edema, or how this 
feature will improve enrollees transferring ability. The requested power leg rests exceed the enrollees medical 
needs.  
 
Regarding the electronic connection, the enrollee has one power option of power tilt on the approved 
wheelchair. In this case, the requested electronic connection is not medically necessary for the enroll to be able 
to control 2 or more power options through the joystick. The requested expandable controller exceeds the 
enrollees medical needs and does not meet Medicare medical necessity criteria. 
 
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 elevating legs rests and electronic connection have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the elevating legs rests (E1012) and electronic 
connection (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal, premolar tooth, (D3320) provided on May 11, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you were experiencing severe pain. You say that 
this service was an emergency. You also say that you feel this should be covered. The Plan denied your 
request. The Plan says root canal is not listed as a covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the root canal is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal, 
premolar tooth, (D3320) provided on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64625). 
 
You asked the Plan to pre-approve the RFA. You say that the enrollee has received right sacroiliac (SI) joint 
injections on February 24, 2022, and August 3, 2022, with greater than 80% relief. You say that RFA will 
reduce pain, improve function and range of motion and improve the enrollee's quality of life. You also say that 
the requested service is medically necessary. The Plan denied your request. The Plan says the requested service 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the RFA. Our reviewer says that the 
requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation does not indicate there would be a long-term benefit for the enrollee's 
diagnosis. Therefore, the reviewer found that the provided documentation does not support that the requested 
RFA is 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - one to three teeth per 
quadrant (D4342) provided on March 29, 2022. 
 
You asked the Plan to pay for scaling and root planing. You say that you don't understand how the plan does 
not cover treatment for periodontitis. The Plan denied your request. The Plan says this service is not a covered 
service under your dental benefit 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 pay for 
periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic (D6245), and crown (D6740) for a fixed bridge. 
 
You asked the Plan to pre-approve pontic and crown for a fixed bridge. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
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 pontic and 
crown for a fixed bridge 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 pontic and crown for a fixed bridge. 
Our reviewer says that criteria are not met for these services. Our physician reviewer found the request has 
been made for a bridge from #22-27, with pontic replacements for teeth #23,24,25 and 26 which are 
periodontally compromised. Tooth #22 also has noted bone loss with about 40% of the support 
compromised. There is nothing in the record that indicates that periodontal treatment has been initiated, and no 
history of the stability of the lower left canine tooth which is treatment planned to help replace four other 
teeth. A long span bridge may be capable of having an abutment that has some periodontal compromise if it is 
shown to be stable over time, which necessitates continued periodontal treatment and monitoring. As there is 
no indication that the periodontal condition of #22 is being addressed, there can be no determination that the 
tooth would be a stable abutment over time. A compromised abutment such as #22 cannot be utilized in a 
bridge where the periodontal condition has not been addressed and assessed for stability.  
 
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 pontic and crown for a fixed bridge have not been met. Therefore, we decided 
that the Plan does not have to pre-approve pontic (D6245), and crown (D6740) for a fixed bridge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140), intraoral - periapical first 
radiographic image (D0220), endodontic therapy, molar tooth (excluding final restoration) (D3330), periodic 
oral evaluation, amalgam - one surface, primary or permanent (D2140), periodic oral evaluation (D0120), and 
prophylaxis - adult (D1110) provided on February 21, 2022 to March 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you say that you have been going to the same 
dentist since 1984 as an established patient and would prefer not to have to change. You also say that the 
network choices are confusing and not very clear. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental 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. 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for limited oral evaluation (D0140), intraoral - periapical first radiographic image (D0220), endodontic 
therapy, molar tooth (excluding final restoration) (D3330), periodic oral evaluation, amalgam - one surface, 
primary or permanent (D2140), periodic oral evaluation (D0120), and prophylaxis - adult (D1110) provided on 
February 21, 2022 to March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced pneumatic compression device (PCD). 
 
You asked the Plan to pre-approve the requested device. You say that a basic pump was trialed. The Plan 
denied your request. The Plan says the enrollee failed home usage of a basic device. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications. 
 
We looked at the file and Medicare rules. The records provided indicate the enrollee tried a basic pump for 30 
minutes. There are insufficient medical records showing at least four weeks of regular, daily, multiple-hour 
home usage of a basic pump.  Based on this information, we decided that Medicare rules for coverage of the requested device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an advanced pneumatic compression 
device (PCD).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services (97530, 97110, 97535) provided from 
January 3, 2022 to January 13, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the therapeutic services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  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 therapeutic services (97530, 97110, 97535) 
provided from January 3, 2022 to January 13, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve deep gum and root cleaning, all four quadrants (D4341). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the tooth must have noticeable bone loss. 
 
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 services 
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 services. Our reviewer says that the 
requested dental services are not medically reasonable or necessary. Our physician reviewer found that a 
review of the documentation indicates the presence of 5-9mm periodontal pockets and bleeding when probed. 
Periodontal scaling and root planing is medically reasonable and necessary to treat the patient's periodontal 
disease. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve deep gum and root cleaning, all four quadrants (D4341).  
 
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.