Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that SNF care is need to that you can get better. 
You have very limited mobility and would need to rely on others for help if sent home. The Plan denied your 
request. The Plan says your condition is now stable, and you do not require skilled services on a daily basis. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 72-year-old man 
with a history of alcoholism and chronic pain, who was admitted to the hospital on 3/10/22 with a femur 
fracture, which was surgically treated on 3/12/22. The enrollee is ambulating 60-90 feet with standby 
assistance. 
 
The records do not show that the enrollee has skilled nursing needs. The enrollee may benefit from skilled 
therapy services, but this is not required on a daily basis. The documentation does not support that it is 
medically reasonable and necessary to provide skilled therapy services on a "daily basis" on an inpatient basis, 
in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with proton therapy (77523). 
 
You asked the Plan to pre-approve proton therapy. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested service is experimental/investigational. 
 
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 proton therapy. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is not enough data to support proton therapy for meningioma as an accepted standard 
for routine care, and the case records did not sufficiently demonstrate the need for proton therapy. Routine use 
of proton therapy is not within accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with proton therapy (77523).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen equipment to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve oxygen equipment to be provided by an OON provider. You say that the 
items are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
oxygen equipment to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from March 17, 2022. 
 
You asked the Plan to pre-approve SNF care. You say that your surgeon suggests that you still need additional 
occupational therapy. The Plan denied your request. The Plan says the stay is not medically necessary based on 
SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require continued skilled nursing 
services, i.e., are the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment. You may benefit from continued 
skilled therapy services. The documentation does not support that it is medically reasonable and necessary to 
provide skilled services on a "daily basis" on an inpatient basis, in a SNF setting beyond March 17, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from March 17, 2022.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on March 11, 2022 with hypoxia and vomiting.  
 He was medically stable for discharge as of March 14, 2022. On March 15, 2022 he ambulated 100 feet with 
minimal assistance and needs minimal assistance for activities of daily living. At the current functional level, 
the enrollee does not need intensive therapies, consisting of at least three hours of therapy per day at least five 
days per week with multidisciplinary approach to daily therapy in an IRF. The IRF services are not reasonable 
or 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 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 the acute inpatient hospital care for the total knee 
arthroplasty (CPT code 27447). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee's past medical history 
is extensive and due to hypercapnia, the enrollee has tried and failed average volume-assured pressure support 
(AVAPS) and bilevel positive airway pressure (BiPAP); provider requests payment on the denied claim based 
on included records as services were medically necessary. The Plan denied your request. The Plan says the 
inpatient hospital stay is not necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found inpatient services were requested related to this procedure. The enrollee's 
past medical history is extensive and due to hypercapnia, they have tried and failed AVAP) and BiPAP. 
However, the enrollee was documented as having been cleared for surgery suggesting they were low risk for 
cardiovascular events. No mention of any instability or other condition that would expect the enrollee to require 
inpatient services that would likely cross two (2) midnights related to this lower risk procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care for the total knee arthroplasty (CPT code 
27447).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tremfya injection (J1628). 
 
You asked the Plan to pre-approve Tremfya. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the provider confirmed that the medication is not being administered by the 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Tremfya injection (J1628).  
 
Benefits for Tremfya may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical alert system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not serve a diagnostic or therapeutic purpose. 
 
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 medical alert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
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 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no required skilled nursing services 
identified. You may benefit from skilled therapy services. The documentation does not support that it is 
medically reasonable and necessary to provide skilled services on a daily basis on an inpatient basis, in a 
skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a queen-sized adjustable bed frame (E1399). 
 
You asked the Plan to pre-approve a bed frame. You say that you have been sleeping in reclining chairs which 
are not meant to be slept on. You are asking for approval for the base/frame, not the entire bed. The Plan 
denied your request. The Plan says a queen-sized adjustable bed frame and does not serve a medical purpose. 
 
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 queen-sized adjustable bed frame (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that the total electric hospital bed is 
medically necessary. The Plan denied your request. The Plan says this equipment is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like reconsideration 
because the requested device is medically necessary. The Plan denied your request. The Plan says the 
pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis 
during and/or following surgery, at home, or in any setting. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says insulin is not being used three or more times per day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial preventive physical examination (G0402) and hospital 
outpatient clinic visit for assessment and management of a patient (G0463) provided on August 11, 2021. 
 
You asked the Plan to pay for the medical evaluation and management services. You say that you would like 
this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this 
claim has not been billed in accordance with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that multiple medical visits 
on the same day in the same revenue center may be submitted on separate claims. Hospitals should report 
condition code G0 on the second claim. We looked at the file and Medicare rules. In this case, this claim has not been billed with a condition code of 
G0 for the multiple medical visits on the same day in the same revenue center. Without this condition, the 
claim cannot be paid as billed. Based on this information, we decided that Medicare rules for coverage of the 
medical evaluation and management services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial preventive physical examination (G0402) and hospital outpatient clinic visit for 
assessment and management of a patient (G0463) provided on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam (D0364), Removal of Impacted Tooth - 
Completely Bony (tooth #1, #16, #32) (D7240), Removal of Impacted Tooth - Completely Bony, Unusual 
Surgical Complications (tooth #11) (D7241), Primary Closure of Sinus Perforation (D7261), Excision of 
Benign Lesion Greater Than 1.25 cm (D7411), Bone Replacement Graft For Ridge Preservation - Per Site 
(tooth #9, #10, #11) (D7953), and Collection And Application Of Autologous Blood Concentrate Product 
(D7921). 
 
You asked the Plan to pre-approve cone beam, Removal of Impacted Tooth - Completely Bony (tooth #1, #16, 
#32), Removal of Impacted Tooth - Completely Bony, Unusual Surgical Complications (tooth #11), Primary 
Closure of Sinus Perforation, Excision of Benign Lesion Greater Than 1.25 cm, Bone Replacement Graft For Ridge Preservation - Per Site (tooth #9, #10, #11), and Collection And Application Of Autologous Blood 
Concentrate Product. You say that the services are necessary. The Plan denied your request. The Plan says the 
requested services are 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 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 cone 
beam (D0364), Removal of Impacted Tooth - Completely Bony (tooth #1, #16, #32) (D7240), Removal of 
Impacted Tooth - Completely Bony, Unusual Surgical Complications (tooth #11) (D7241), Primary Closure of 
Sinus Perforation (D7261), Excision of Benign Lesion Greater Than 1.25 cm (D7411), Bone Replacement 
Graft For Ridge Preservation - Per Site (tooth #9, #10, #11) (D7953), and Collection And Application Of 
Autologous Blood Concentrate Product (D7921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553).