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 enrollee will benefit from the physical and 
occupational therapies and the nursing and physician oversight offered at the IRF level of care. The Plan denied 
your request. The Plan says the enrollees needs can be safely provided in another setting such as a Skilled 
Nursing Facility (SNF) or home health care. The Plan says 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 the enrollees nursing, medical, and rehabilitation needs are not of a complexity 
level which would require treatment in an IRF. The enrollee received inpatient hospital care for surgical repair 
of a hip fracture after suffering a fall. Our reviewer found that the enrollees medical problems are stable. There 
are no documented complex nursing or rehabilitation needs. The medical record indicates a need for physical 
and/or occupational therapy, but there is no evidence suggesting these therapies must be provided in an 
intensive rehabilitation therapy program. Our physician reviewer found no reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive therapy program provided in an IRF. 
The enrollees medically necessary care can be provided at a lower level of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite, one surface, posterior (D4266) 
and a bone replacement graft for ridge preservation, per site (D7953). 
 
You asked the Plan to pre-approve a resin-based composite and a bone graft replacement graft. You say that the 
enrollee needs this molar to restore chewing functions and prevent more complications. Ultimately, this dental 
work will improve his dental health. The Plan denied your request. The Plan says the procedure codes are not 
listed and therefore not covered by the Plan. 
 
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 a 
resin-based composite, one surface, posterior (D4266) and a bone replacement graft for ridge preservation, per 
site (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), 
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial 
issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and 
mounting hardware (CPT code E2313) and electronic connection between wheelchair controller and two or 
more power seating system motors, including all related electronics, indicator feature, mechanical function 
selection switch, and fixed mounting hardware (CPT code E2311). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The seat lift does not serve a primary 
medical purpose. The upgraded electronics (expandable controller, harness and electronic connector to 2 power 
options) are not medically necessary. They are necessary when there is a medical need to control power options 
though the joystick. The notes do not show a medical need to control the power options through the joystick. 
The power options can be controlled using their own switches. These switches can be made any size without 
asking for a separate request. They can be made from any material without asking for a separate request. All of 
this can be done without the need to use the joystick to control the power features. Therefore, we decided that 
the Plan does not have to pre-approve power seat elevation system (CPT code E2300), expandable controller, 
including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), 
harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT 
code E2313) and electronic connection between wheelchair controller and two or more power seating system 
motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed 
mounting hardware (CPT code E2311).
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 you want to see a doctor who can see you at this 
facility. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been 
met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you are medically stable and do not need physical medicine and rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. You have no acute rehabilitation nursing needs identified or 
documented. At the current functional status, you do not need intensive therapies consisting of at least 3 hours 
of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. An IRF admission is not 
medically necessary based on lack of medical complexity and acute rehabilitation nursing needs and current 
functional status. While you may benefit from continued physical therapy, your rehabilitation needs can be 
safely provided in a lower intensity and alternate setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 more for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on September 23, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that you were told 
the treating provider was participating. You also say that you should not be held responsible for these charges. 
The Plan denied your request. The Plan says your benefits were applied correctly, and no adjustment is needed. 
 
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, because you received these services 
from an OON provider, the Plan paid the allowed amounts for the services, and you are responsible for the 
difference between the billed amounts and allowed amounts. Therefore, we decided that the Plan does not have 
to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on September 23, 2021 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for an out-of-network provider 
specialist for the surgical services (CPT code(s): 61458 and (61781) to be provided by an out-of-network 
provider. 
 You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there are at least 5 in-network Neurosurgeons within your geographic area with the 
training and expertise to perform the requested surgical procedure. The Plan states you would have to see your 
requested provider using your out-of-network benefits as explained in your EOC, as there are in-network 
providers in the region with no evidence that in-network specialist resources in the same geography to you have 
been exhausted. The Plan states there are also tertiary in-network specialist options available, as well as out of 
state university options that are in-Network; therefore, no in-network inadequacies are seen. The Plan states the 
CPT codes and request for inpatient DRG are approved. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
There are at least 5 in-network Neurosurgeons within your geographic area with the training and expertise to 
perform the requested surgical procedure. You are a Preferred Provider Organization member who will have to 
see this provider using you out-of-network benefits as explained in you Evidence of Coverage, as there are in-
network providers in the region with no evidence that in-network specialist resources in the same geography to 
you have been exhausted. Therefore, we decided that the Plan does not have to pre-approve an in-network 
exception for an out-of-network provider specialist for the surgical services (CPT code(s): 61458 and (61781) 
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 seat elevator represented by code E2300, a cup holder 
represented by code K0108, an expandable controller represented by code E2377, a harness represented by 
code E2313, and an electrical connection between the wheelchair and two or more motors represented by code 
E2311. 
 
You asked the Plan to pre-approve E2300, K108, E2377, E2313, and E2311. You say that the records provided 
support the need for the items which remain in dispute. The Plan denied your request. The Plan says the 
upgraded electronics are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules also say that a power seat elevation feature represented by code E2300 is non-
covered because it is not primarily medical in nature. 
 
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 E2300, K108, E2377, E2313, and 
E2311. Our reviewer says that the expandable controller, the harness, and the electrical connection are not 
considered medically reasonable and necessary in this case. Our physician reviewer found these items exceed 
the enrollee's medical needs. The enrollee does not require a ventilator, or non-proportional input devices. The 
enrollee does not require a separate display, other electronic devices, or an attendant control. The enrollee has 
power options on the wheelchair, but the enrollee does not need to control the power options through a 
joystick. The enrollee's upper extremity strength supports that the enrollee can control any power options 
through their own switches. The power seat elevation feature represented by code E2300 is non-covered, as it is 
not primarily medical in nature. The dub holder represented by code K0108 is non-covered, as it does not 
primarily serve a medical purpose.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of E2300, K108, E2377, E2313, and E2311 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a seat elevator represented by code E2300, a cup holder 
represented by code K0108, an expandable controller represented by code E2377, a harness represented by 
code E2313, and an electrical connection between the wheelchair and two or more motors represented by code 
E2311.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 2 power wheelchair, very heavy duty, 
captains chair, patient weight capacity 451 to 600 pounds (K0827). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you have tendonitis in your elbows and 
arthritis in both knees and elbows. The walker is not helping the upper body and you do not have anyone to 
push you in a wheelchair. With the tendonitis, you cannot push the wheelchair with your own arms. The Plan 
denied your request. The Plan says the records do not support that the requested power wheelchair is medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the documentation supports that the enrollee has severe morbid obesity 
and chronic pain in the knees. There is no specialty evaluation that was performed by a licensed/certified 
medical profession to determine what type of assistive device is most appropriate.  Furthermore, the 
documentation does not support that the enrollee requires multiple power options. The requested group 2 power 
wheelchair is not medically 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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the group 2 power wheelchair, very heavy duty, captains chair, patient weight 
capacity 451 to 600 pounds (K0827).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth extraction (D7210). 
 
You asked the Plan to pre-approve a tooth extraction. You say that your dentist does not want to take the 
chance in removing the tooth and referred you to an oral surgeon. Your mouth is infected, and you cannot keep 
getting pain medication. The Plan denied your request. The Plan says dental services are only covered when 
provided by a participating general dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a tooth 
extraction when the services are performed by a participating general dentist.  
 
We looked at the file and Medicare rules. Specifically, dental services are covered when services are provided 
by a participating general dentist. Based on this information, we decided that the Plan's rules for coverage of a 
tooth extraction have not been met. Therefore, we decided that the Plan does not have to pre-approve a tooth 
extraction (D7210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve armrests for the power wheelchair. 
 
You asked the Plan to pre-approve armrests. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that armrests are already included with the 
request of the power tilt and recline. A separate request for arm rests are considered unbundled and therefore, 
not covered. Based on this information, we decided that Medicare rules for coverage of armrests have not been 
met. Therefore, we decided that the Plan does not have to pre-approve armrests for the power wheelchair.
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 can be transferred to
LTACH level of care for continuation of complex medical needs that require ongoing acute care. The Plan
denied your request. The Plan says the documentation fails to indicate the enrollee requires this level of care.
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 is receiving appropriate care at the present setting. The enrollee does not
require services at the LTACH that are not available at the acute care hospital 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 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 preventive procedure (D1999) provided on January 13, 2022. 
 
You asked the Plan to pay for the preventive procedure. You say that you contacted the Plan and asked them 
for an in-network provider, but instead they gave you an out-of-network provider. The Plan denied your 
request. The Plan says this service is not covered 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 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 pay for the 
preventive procedure (D1999) provided on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical reduction of fibrous tuberosity (D7972). 
 
You asked the Plan to pre-approve surgical reduction. You say that removing the tissue is necessary to fit the 
enrollee for dentures. The Plan denied your request. The Plan says surgical reduction of fibrous tuberosity 
(D7972) is not covered by the Plan's routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical reduction of fibrous tuberosity (D7972).
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 you believe the enrollee's medical management and 
rehabilitation needs require an inpatient rehabilitation stay and close physician supervision. The Plan denied 
your request. The Plan says based on Medicare guidelines, the IRF services you are requesting do not meet the 
requirements for approval. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy 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.