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

 
We decided that the Plan does not have to pay for the inpatient hospital admission for the shoulder surgery 
(CPT code 23472). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service is necessary. The Plan 
denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to 
undergo this elective procedure. The Plan states the planned procedure listed under CPT code 23472 are not 
listed on the CMS Inpatient Only List. The Plan states the procedure is currently approved as an ambulatory 
procedure. The Plan states there is no documentation provided to support the expectation the enrollee will 
require a greater than 2 midnight stay. The Plan states if the enrollee experiences any peri- or post- operative 
complications, reconsideration for inpatient level of care can be performed on concurrent review with updated 
clinical information. 
 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 pay for 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 the review has determined that the record did not show that the inpatient hospital care 
for the elective shoulder joint replacement surgery is 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital admission for the shoulder surgery (CPT code 23472).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous (around-the-clock) live-monitoring of
electrical activity of the heart (mobile cardiac outpatient telemetry - MCOT) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not show detection of rare irregular heartbeats that cause symptoms.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has a history of palpitations, and this was the stated indication for this request. As such,
guidelines would not support a need for MCOT monitoring in this setting. In summary, there was insufficient
documentation to support the medical necessity for an MCOT monitor in this patient's clinical management.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continuous (around-the-clock) live-monitoring of electrical activity of the heart (mobile
cardiac outpatient telemetry - MCOT) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you feel that the enrollee would benefit from
continued coverage for more physical therapy to help them gain strength. The Plan denied your request. The
Plan says medical necessity cannot be established for continued SNF level of coverage.

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 based on the documentation provided, the enrollee no longer qualifies for SNF
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have
documented skilled therapy needs. Daily skilled services are not shown to be required to establish a
maintenance program or to prevent deterioration of the enrollee's condition.

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 continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
April 19, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were unfairly punished for 
switching dentists when you could not get into the previous one in a timely manner. The Plan denied your 
request. The Plan says your benefit for the requested service has already 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, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service May 21, 2020. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 
19, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to waive the cost-sharing and pay for an extremity vein scan and cone beam computed 
tomography (CT) scan provided in the Hellenic Republic (Greece) on July 12, 2021, and July 16, 2021. You 
say that you had pain for days and needed these tests. The Plan says that the cost-sharing amount you are being 
charged is correct, and the denial of payment for the cone beam CT scan is correct because supporting medical 
records were not submitted to show why this scan was needed. 
 We decided that the Plan has to waive the deductible for extremity vein scan.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly states that supplemental 
benefits, emergency care, and urgent care services are excluded from the Plan deductible. All services 
furnished outside of the United States and its territories are excluded from Medicare coverage except in the 
circumstances specified in the previous section; therefore, the Plans worldwide coverage benefit is a 
supplemental benefit by its nature. 
 
The Plan says that you must pay $59.29 deductible amount for extremity vein scan. However, this extremity 
vein scan is excluded from the Plan deductible. Therefore, we decided that the Plan has to waive the deductible 
for extremity vein scan.  
 
We also decided that the Plan does not have to waive the cost-sharing and pay for extremity vein scan 
and CT scan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $50 
copayment for worldwide urgent care services at a specialists office. The rules also say that the provider, 
supplier, or beneficiary  as applicable  must furnish to the Plan sufficient information to determine whether 
payment is due for a claim. 
 
We determined that you have not submitted sufficient information to the Plan to justify payment of the cone 
beam CT scan that you are requesting reimbursement for. Specifically, no supporting medical records were 
submitted to show why this test was needed or to confirm that it was performed. Therefore, we decided that the 
Plan does not have to waive the cost-sharing and pay for extremity vein scan and CT scan. 
 
Therefore, we decided that the Plan must reduce your cost-sharing from $59.29 deductible amount to $50 
copayment amount and thus reimburse you an additional $9.29. 
 
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 an electronic connection for a power wheelchair.

You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee's upper limb strength and function are adequate for the member to be able to
control the power options using their own switches which are included in the allowance of these power options.

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 item. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the original decision was appealed and partially overturned indicating that a group 2 power
wheelchair was considered medically necessary, but the electrical connection was not. There is insufficient
documentation indicating what group type of power wheelchair is ultimately required and what type of power
features are required, including power tilt and power elevating leg rests. Without this information, it cannot be
determined if the electrical connection (E2311) is medically necessary at this time.

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 item have not been met. Therefore, we decided that the Plan does not have
to pre-approve an electronic connection for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower limb prosthesis flexible protective outer surface 
cover (L5964) and osseosynchronization socket design (L5999). 
 
You asked the Plan to pre-approve lower limb prosthetic components. You say that the enrollee needs a 
working prosthetic leg or will be at risk for more severe issues in the future. The Plan denied your request. The 
Plan says the requested lower limb prosthetic components 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.  
 
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 lower limb prosthetic components. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation indicating that the enrollee has special needs for 
protection against unusually harsh environmental situations where it is necessary to protect the lower limb 
prosthesis beyond the level of protection that is already afforded. Additionally, there is insufficient medical 
literature to support the use of osseosynchronization socket design versus standard socket design for the 
enrollee in terms of superior functional outcomes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lower limb prosthesis flexible protective outer surface cover 
(L5964) and osseosynchronization socket design (L5999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #31. 
 
You asked the Plan to pre-approve a crown. You say that food is getting trapped between your teeth, and 
pressure from the upper teeth is causing you pain. The Plan denied your request. The Plan says a crown is not 
needed to fix your tooth. 
 
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 crown 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 a crown. Our reviewer says that the 
documentation provided does not meet the criteria for coverage for a crown (D2740) for tooth #31. Our 
physician reviewer found due to an open contact between #30 and 31 there is food impaction. Our reviewer 
also found that tooth #31 does not have significant coronal breakdown due to caries or fracture to warrant a 
crown restoration. 
 
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 a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide/lift (E1399). 
 
You asked the Plan to pre-approve a stair lift. You say that the requested stair lift is a medical necessity not a 
convenience due to the enrollee's frequent falls, gait instability and physical debility. The Plan denied your 
request. The Plan says your request is not a covered benefit because a stair lift is not primarily and 
customarily used to serve a medical purpose and is generally useful to a person in the absence of illness or 
injury. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide/lift (E1399).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an autogenous connective tissue graft procedure (D4273) and 
intravenous moderate sedation (D9243, D9239). We also decided that the Plan does not have to pre-approve 
other drugs/medicaments (D9630).  
 
You asked the Plan to pre-approve an autogenous connective tissue graft procedure (D4273), intravenous 
moderate sedation (D9243, D9239), and other drugs/medicaments (D9630). You say that these services should 
be covered. The Plan denied your request. The Plan says that your annual benefit maximum has been 
exhausted. The Plan also says that other drugs/medicaments (D9630) are not covered by your dental benefits. 
 
We decided that the Plan has to pre-approve an autogenous connective tissue graft procedure (D4273) 
and intravenous moderate sedation (D9243, D9239).  
 
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 did not provide documentation showing your annual benefit maximum 
has been exhausted. Therefore, we decided that the Plan has to pre-approve an autogenous connective tissue 
graft procedure (D4273) and intravenous moderate sedation (D9243, D9239).  
 
We also decided that the Plan does not have to pre-approve other drugs/medicaments (D9630). 
 
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, other drugs/medicaments are not 
among those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve 
other drugs/medicaments (D9630). 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250). 
 
You asked the Plan to pre-approve the removal of residual tooth roots (D7250). You say that you have bone 
fragments left in your bottom gums casing pain when you eat. The Plan denied your request. The Plan says this 
is 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 the 
removal of residual tooth roots (D7250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) with a 
periodontist. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation (D0150) with a periodontist. You say that 
two different procedures have been performed and none of them have worked out. You also say that you are in 
pain, so the provider wants to perform a biopsy to find out what is causing this gum infection, and to provider a 
proper treatment. The Plan denied your request. The Plan says dental services performed by a periodontist are 
not covered. 
 
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. This benefit covers dental services only when they are performed by 
participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive 
oral evaluation (D0150) with a periodontist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve these services. 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 ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found you have chronic obstructive
pulmonary disease (COPD) and were admitted to the hospital on July of 2022 with worsening COPD. No
arterial blood gas (ABG) study was done in the hospital, but an ABG after several days of treatment showed
you had no carbon dioxide treatment at the time. You do not meet the criteria for coverage and the home
ventilator is 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric hospitalization provided from 
January 27, 2021, to January 29, 2021. 
 
You asked the Plan to pay for the inpatient psychiatric hospitalization. You say that the hospital submitted the 
precertification request to the incorrect company in error. You also say that the error was discovered after the 
enrollee had been discharged. The Plan denied your request. The Plan says the clinical information provided 
does not substantiate the need for treatment at the requested level of care from January 27, 2021 forward. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 pay for the inpatient psychiatric hospitalization. Our 
reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care 
beyond January 27, 2021. Our physician reviewer found it was not expected this enrollee would improve in a 
reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or 
others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats 
of safety. Our reviewer also found that it did not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than 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 the inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient psychiatric hospitalization provided from January 
27, 2021, to January 29, 2021.