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 admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says daily skilled services that can only be provided on an inpatient basis are not 
required. 
 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 admission. Our reviewer says that 
the requested services are not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that you require skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. The records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care. There is no 
documentation that daily skilled services are required. You have been non-weight bearing with her left lower 
extremity since February 2022 and this restriction persists until cleared by orthopedics for ability to weight 
bear (reportedly this will be in another month). The provided records do not document a significant decline in 
your functional status compared to her recent baseline to necessitate daily inpatient skilled therapy services. 
There is no documentation that you require the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the home with home health care or in a long-term care facility on a part time basis appear 
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 the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors, including all related electronics, indicator feature, mechanical 
function selection switch, and fixed mounting hardware (CPT code E2311), expandable controller, including 
all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377) and harness 
for upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT code E2313). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Upgraded electronics (electronic 
connection, expandable controller and harness) cannot be covered per Medicare rules. They are necessary when 
there is a medical need to control power options though the joystick. The notes do not show a medical need to 
control the power options through the joystick. The power options can be controlled using their own switches. 
These switches can be made any size without asking for a separate request. They can be made from any 
material without asking for a separate request.  All of this can be done without the need to use the joystick to control the power features. Therefore, we decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function 
selection switch, and fixed mounting hardware (CPT code E2311), expandable controller, including all related 
electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377) and harness for 
upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT code E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve replacement dentures. You say that the initial set of dentures did not fit 
properly. You say that it was adjusted multiple times. You also say that you are not able to chew or eat 
properly. The Plan denied your request. The Plan says replacement of removable and fixed prostheses is 
covered only if the existing prostheses were inserted at least 60 months prior to the replacement. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and partial dentures are covered every 
60 months, the frequency limit has been reached. The record shows that the Plan paid for partial dentures that you received on March 20, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower denture (D5214).
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 need more intense rehabilitation. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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.  While you may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation program. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the device in dispute is 
medically necessary. The Plan denied your request. The Plan says the requested item is non-covered. 
 
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 
pre-approve a pneumatic compression device (E0676).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently 
unstable for transfer to an LTACH. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. 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 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implant placements (D6010) for twelve teeth. 
 
You asked the Plan to pre-approve twelve implants. You say that dental implants are necessary. The Plan 
denied your request. The Plan says implants are not covered by your dental 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 
dental implant placements (D6010) for twelve teeth.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup (D2950), and endodontic therapy (D3310) 
provided by a participating provider on December 17, 2021. 
 
You asked the Plan to pay for a core buildup and endodontic therapy. You say that you were told you would 
receive a 30% discount. The Plan denied your request. The Plan says the rendered dental services are not 
covered dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
buildup (D2950), and endodontic therapy (D3310) provided by a participating provider on December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on April 21, 
2021, to October 20, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered dentist has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until April 1, 2022. Therefore, we decided that the Plan does not have to 
pay for dental services provided by an opt-out provider on April 21, 2021, to October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable adaptive rehab device. 
 
You asked the Plan to pre-approve the requested device. You say that the device increases range of motion and 
stimulates tissue healing. The Plan denied your request. The Plan says exercise equipment is a non-covered 
device. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We looked at the file and the rules. The item at issue in this appeal does not serve a purpose that is primarily 
medical in nature. Therefore, we decided that the Plan does not have to pre-approve a portable adaptive rehab 
device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the maxillary partial denture (D5225) and mandibular 
partial denture (D5226) provided on July 22, 2021. 
 
You asked the Plan to pay more for the partial dentures. You say that you cannot use the dentures because they 
hurt your mouth. The Plan denied your request. The Plan says you pay 50% of the total amount for dentures 
from an in-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50% 
coinsurance for partial dentures. Therefore, we decided that the Plan does not have to pay more for the 
maxillary partial denture (D5225) and mandibular partial denture (D5226) provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), and filling (D2393) provided on November 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that you pulled a tooth out while flossing. You say 
that your regular dentist did not return your call. You also say that this visit was an emergency and should be 
covered. The Plan denied your request. The Plan says the annual maximum 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual maximum benefit has been 
exhausted. The record shows that the Plan paid $1,000 for dental services received on May 10, 2021. The 
Evidence of Coverage clearly states that you are responsible for any amount above the dental coverage limit. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-
ray (D0220), and filling (D2393) provided on November 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prosidyan Fibergraft. 
 
You asked the Plan to pre-approve Prosidyan Fibergraft. You say that the enrollee is having a lot of hand 
numbness. You say that the enrollee's symptoms are getting worse, and he cannot walk. The Plan denied your 
request. The Plan says the guidelines for coverage have not been met because the provider has not supplied a 
detailed description, including the manufacturer, brand name, and device name for the requested implants. 
 
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 Prosidyan Fibergraft. Our reviewer says 
that Prosidyan Fibergraft is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
Allograft to be an effective and/or safe treatment for use in cervical fusion procedures. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prosidyan Fibergraft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Prosidyan Fibergraft.
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 SNF admission. You say that SNF admission is medically necessary. The 
Plan denied your request. The Plan says SNF admission is not medically necessary for the patient. 
 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the medical records, the patient 
does not require skilled nursing services. The records do not document the need for intravenous medications, 
new tube feeding, or ostomy care or daily complex wound care. The patient does have skilled therapy needs, 
but there is no documentation that daily skilled services are required. Although the patient is weak and 
debilitated, the provided records do not document a significant decline in the patients functional status 
compared to her recent baseline to necessitate daily inpatient skilled therapy services. In addition, there is no 
documentation that the patient requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the home with home health care or in a long-term care facility on a part time basis appear 
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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Lite Test In Vitro strips. 
 You asked the Plan to pre-approve these services. You say that you are currently using these strips. The Plan 
denied your request. The Plan says the services are available from the preferred provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. 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 FreeStyle Lite Test In Vitro strips.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a removal of a bone spur of the jaw. 
 
You asked the Plan to pre-approve the removal of a bone spur of the jaw. You say that you have a projection 
from the bone which you need removed because you cannot be fitted with lower dentures with it in place. The 
Plan denied your request. The Plan says that the requested services are not a covered benefit because they are 
dental in nature. 
 
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 Plans denial rationale that the requested services cannot be covered because 
they are dental services is not supported and is not appropriate in this case. The Plans contract clearly shows 
that dental services are covered as a supplemental benefit. The Plan evidently did not consider whether the 
services could be covered under this benefit and did not respond to a request for additional information 
regarding this issue. Review of covered services under the dental benefit shows that certain oral surgery can be 
covered, including removal of an exostosis, which is also known as a bone spur. Since the Plan gave no 
alternate denial rationale to explain why the requested service would not be covered under the eligible dental 
codes, we find that the denial is not substantiated. Therefore, we decided that the Plan has to pre-approve a 
removal of a bone spur of the jaw.  
 
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.