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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF care is not medically necessary for this patient as they can be managed 
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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for coronary artery bypass grafting. Their medical problems are stable, and they have no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 17, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 17, 2021, by an out-of-network 
(OON) provider.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF admission is not medically necessary because you can be managed 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical incision infection and acute kidney failure. Your medical problems are stable, and you have no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 guided tissue regeneration (D4266), a bone 
replacement graft (D4263), and an endosteal implant (D6010), provided by a participating provider. 
 
You asked the Plan to pre-approve a guided tissue regeneration, a bone replacement graft, and an endosteal 
implant. You say that you need this implant because you need to be able to eat. The Plan denied your request. 
The Plan says the requested dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266), a bone replacement graft (D4263), and an endosteal implant (D6010), 
provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system, aluminum soft roll caster wheels, and 
push handle. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The items at issue in this appeal are for use outside of the home. Although these items may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit system, aluminum soft roll caster wheels, and push handle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection between wheelchair controller 
and two or more power seating system motors, the controller upgrade, and the harness upgrade. 
 
You asked the Plan to pre-approve the electronic connection between wheelchair controller and two or more 
power seating system motors, the controller upgrade, and the harness upgrade. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested items. 
 
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 the enrollee has a four out of five 
bilateral upper limb strength. This means the enrollees upper limb strength and function are adequate for the 
enrollee to be able to control the power options using their own switches which are included in the allowance 
of the approved power options. There is no documentation of a medical need to control the power options 
through the joystick. The power options can be controlled using their own switches. 
 
Based on this information, we decided that Medicare rules for coverage of the electronic connection between 
wheelchair controller and two or more power seating system motors, the controller upgrade, and the harness 
upgrade have not been met. Therefore, we decided that the Plan does not have to pre-approve the electronic 
connection between wheelchair controller and two or more power seating system motors, the controller 
upgrade, and the harness upgrade.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic consultation (D9310) and an extraction 
(D7210) provided by an oral surgeon. 
 
You asked the Plan to pre-approve a diagnostic consultation and an extraction. You say that you should be able 
to see an oral surgeon. The Plan denied your request. The Plan says the requested services have been correctly 
denied. 
 
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 diagnostic 
consultation and an extraction when the services are provided by a participating general dentist.  
 
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 diagnostic consultation and an extraction have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a diagnostic consultation (D9310) and an extraction 
(D7210) provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120) for teeth 
number 11 and 7. 
 
You asked the Plan to pre-approve a fixed partial denture sectioning (D9120) for teeth number 11 and 7. You 
say that you are appealing with supporting records. The Plan denied your request. The Plan says a fixed partial 
denture sectioning (D9120) is not listed in the EOC and therefore 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 a 
fixed partial denture sectioning (D9120) for teeth number 11 and 7.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a case presentation (D9450) and diagnostic casts 
(D0470) provided by a participating provider. 
 
You asked the Plan to pre-approve a case presentation and diagnostic casts. You say that you need these 
services to help with your dental problems. The Plan denied your request. The Plan says the requested dental 
services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
case presentation (D9450) and diagnostic casts (D0470) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown and core buildup services () 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
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 item or service was exhausted on date of service December 19, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a crown and core buildup services ()
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 the denial. 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 based on the medical records provided there is no documentation 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230) and 
the resin-based composite (D2392) for tooth #30 provided on March 15, 2022, and May 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that your card has dental coverage on it and these 
services should be covered. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the intraoral radiographic images and the resin-based composite are 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 Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral radiographic images (D0220 and D0230) and the resin-based composite (D2392) for tooth #30 
provided on March 15, 2022, and May 19, 2022.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to be more stable and improving and should only require short-term 
additional acute care services that can safely be administered at the current facility until more appropriate for a 
lower level of care. You do not require services at the LTACH that are not already available at the current 
facility. 
 
   
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 dental services on June 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services requested are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
that the requested items are not medically necessary. 
 
The Plan follows Medicare rules. The rules say that an expandable controller with harness and electronic 
connection are necessary for accommodating the functions listed in the Medicare rules section of this letter. 
 
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 an expandable controller with harness 
and electronic connection. Our reviewer says that the requested wheelchair accessories are medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee has conditions which 
create limited strength in the upper and lower extremities as well as reduced range of motion due to 
contracture. The expandable controller with harness and electronic connection are necessary for the enrollee to 
operate the Group 3 power wheelchair base. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection have been met. 
Therefore, we decided that the Plan has to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tenex procedure. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
Achilles tendinitis of the right leg and gastrocnemius equinus bilaterally. There is limited published, large-
scale, long-term peer-reviewed literature that shows this request to be an overall effective treatment for the 
noted pathology. Further studies are needed to demonstrate the efficacy of the Tenex procedure for the Achilles 
tendon. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested Tenex procedure, in this case, is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Tenex procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Infed and 
Venofer. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternatives. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternatives. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).