Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473), a 
consultation (D9310), therapeutic parenteral drugs (D9612), and deep sedation (D9222, D9223). 
 
You asked the Plan to pre-approve the dental services. You say that you only have 12 teeth. The Plan denied 
your request. The Plan says that the removal of torus mandibularis (D7473), a consultation (D9310), and 
therapeutic parenteral drugs (D9612) are not covered by your routine dental benefits. The Plan also says that 
your annual dental benefit has been exhausted. 
 
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 removal of torus mandibularis 
(D7473), a consultation (D9310), and therapeutic parenteral drugs (D9612) are not among those covered under 
this benefit. The record shows your annual dental benefit has been exhausted during this prior authorization request. You are responsible for any amount above the annual benefit limit. Therefore, we decided that the Plan 
does not have to pre-approve the removal of torus mandibularis (D7473), a consultation (D9310), therapeutic 
parenteral drugs (D9612), and deep sedation (D9222, D9223).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that daily skilled services are required. There is no documentation that you require 
the services on an inpatient basis, only in a skilled nursing facility setting. Records do not support that services 
in the home with home health care or in a long-term care facility on a part time basis are not appropriate in this 
case. 
 
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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would greatly benefit from three hours 
of intensive therapy daily with the goal of returning home with increased independence. The Plan denied your 
request. The Plan says the records do not indicate the need for admission to an IRF. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the medical record supports a need for physical or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you believe that you have 
to go to this specific location for your requested MRI. The Plan denied your request. The Plan says your 
requested service is medically necessary, but it is not an emergency it is not needed urgently 
within 48 hours. Your plan has MRI available in-network. 
 
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 
magnetic resonance imaging (MRI) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on April 27, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
must include a condition code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. We find that 2 evaluation and management services, with the same revenue 
code, were billed on the same date without a condition code. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the outpatient hospital services provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0656, E0669). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that the enrollee 
has attempted 4 weeks of conservative therapy with compression socks, elevation, and exercise without 
resolution of the enrollee's lymphedema. You believe the compression device will be beneficial to her 
condition. The Plan denied your request. The Plan says the enrollee has not had a failed four-week trial using 
E0650 or E0651 demonstrated by measurements. Therefore, per CMS guidelines, criteria is not met for the 
requested services. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0656, E0669).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tertiary (advanced) oncology services 
 
You asked the Plan to pre-approve the requested services. You say that there are only a few providers who are 
familiar with this cancer. The Plan denied your request. The Plan says a tertiary level of care 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 requested services. Our physician 
reviewer found that you have a diagnosis of Waldenstrom Macroglobulinemia. The record indicates that you 
were previously treated and are currently being monitored. The record does not indicate that you are receiving 
active treatment. The record does not support the medical necessity of the requested service. The record does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
The elements of the coverage criteria are not satisfied. 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve tertiary (advanced) oncology 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 the enrollee fully meets the Medicare 
criteria for LTACH admission. The Plan denied your request. The Plan says admission to the LTACH did not 
meet the Medicare criteria and the enrollee can receive the care that they need in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: 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 a portable ventilator. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says Medicare does not cover ventilators used in 
this way and your needs could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered. Based 
on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive provided from 
April 13, 2021, to March 11, 2022 out of the country. 
 
You asked the Plan to pay for the ophthalmological services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claims do not meet the urgent or emergent criteria. 
Per the members 2021 and 2022 Evidence of Coverage (EOC) booklets, the Plan provides coverage for 
unforeseen medical issues. The member presented to this provider to be treated for macular degeneration, 
which he had already been diagnosed with on October 30, 2020, therefore making this a known issue. The Plan 
has no records that the member called the Plan as the 2021 and 2022 Evidence of Coverage (EOC) booklets 
instructed. In addition, the 2021 and 2022 Evidence of Coverage (EOC) booklets state that the Plan covers emergency services if the member is traveling outside of the United States for less than six months. The 
members claims span a period of over ten months, therefore making them ineligible. 
 
The Plan contract offers a supplemental benefit when traveling out of the United States. The benefit covers 
worldwide emergency services and urgently needed services when out of the country for less than six months. 
 
We looked at the file and the Plans rules. Based on this information, we decided that the Plans rules for 
coverage of the ophthalmological services have not been met. Specifically, the file shows claims do not meet 
the urgent or emergent criteria, that you were being treated for a known medical diagnosis of macular 
degeneration and that you were out of the county for over ten months. Therefore, we decided that the Plan does 
not have to pay for ophthalmological services: medical examination and evaluation, with initiation or 
continuation of diagnostic and treatment program; comprehensive provided from April 13, 2021, to 
March 11, 2022 out of the country.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87798, 87641, 87481, 88305 and 88312) 
provided on February 14, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these are covered services which should be 
paid. The Plan denied your request. The Plan says there is insufficient information to process this claim and 
demonstrate medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 laboratory services have been met. 
Specifically, no medical records were provided to show that these services were medically necessary, ordered 
by the enrollee's treating physician and reported correctly. Therefore, we decided that the Plan does not have to 
pay for laboratory services (87798, 87641, 87481, 88305 and 88312) provided on February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that your best opportunity for recovery is in 
LTACH. The Plan denied your request. The Plan says when you are ready to leave the hospital, you can safely 
receive care in another setting such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that 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 long LTACH services.
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 needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesnt support that IRF 
criteria are met. There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain his functional status. The enrollee can receive further services 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: 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 the enrollee meets LTACH admission 
criteria. You say that the enrollee's ongoing medical needs warrant an LTACH level of care to achieve a safe 
and sustainable discharge. The Plan denied your request. The Plan says criteria for admission to the LTACH 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current 
acute care 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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs long term assistance 
and nutritional assistance. The Plan denied your request. The Plan says the criteria for admission to the LTACH 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transfer and will 
require extended acute care due to the extent and complexity of their current clinical status. The Plan denied 
your request. The Plan says the LTACH services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current 
acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.