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

 
We decided that the Plan does not have to pre-approve additional mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that your current oncologist recommends you 
receive treatment in San Diego due to your tumor still growing. You also say that you are unable to drive and 
have no one who can transport you. The Plan denied your request. The Plan says it was verified that the 
shortest route is 124 miles, and you will have exceeded your benefit mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles.  
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage (A0170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower 
denture (D5120) provided on August 16, 2022. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the dental items provided 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 dental items provided was exhausted on date of service July 22, 2020. Specifically, 
the Plan provides coverage of one upper and one lower complete denture every five years. You previously 
received a complete upper and lower denture on July 22, 2020, which was paid for by the Plan. Therefore, you 
have exhausted the allowable benefit for these items. Therefore, we decided that the Plan does not have to pay 
for the complete upper denture (D5110) and the complete lower denture (D5120) provided on August 16, 2022.
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 meets Medicare criteria and will benefit 
from the acute inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare criteria for admission to and 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for dizziness, diplopia and facial weakness.  Medical problems are stable. There are 
no complex nursing or rehabilitation needs. While the medical records support 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 the enrollee would 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have medical issues that cause you to be 
unable to stand without assistance. The Plan denied your request. The Plan says this item is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a 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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 the enrollee will benefit from skilled therapy 
services in order to maximize his functional status. The Plan denied your request. The Plan says an SNF 
admission 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 daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
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 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 pre-approve a maxillary partial denture  resin base (D5211). 
 
You asked the Plan to pre-approve the dental services. You say that you need a replacement denture. 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 28, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture  resin base 
(D5211).
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 is ready to discharge from STACH and a 
delay will reduce their changes to regain maximum function. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an IRF. The enrollee's needs can be met at a lower 
level of care such as skilled nursing facility (SNF), home with home health services or home with outpatient 
therapy. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-
preferred brands). 
 
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 Freestyle Lite test strips. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the review has determined that 
one of the Plan's preferred brands is sufficient in meeting the enrollee's medical needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Freestyle Lite test strips have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Freestyle Lite test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Utility Flex Card as part of the Special Supplemental 
Benefits for the Chronically Ill. 
 
You asked the Plan to pre-approve a Utility Flex Card. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows 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 a Utility Flex Card. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
indicating that based on physician assessment the enrollee has had 2 or more inpatient admissions in the last 60 
days or has had 3 or more emergency room visits in the last 60 days. The review indicates that the enrollee 
does not meet the qualifications for the Special Supplemental Benefits for the Chronically Ill. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Utility Flex Card have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Utility Flex Card as part of the Special Supplemental Benefits for the Chronically Ill.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the criteria for the 
LTACH admission. The Plan denied your request. The Plan says admission is denied based upon careful 
review of the clinical information. 
 
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 is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they 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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefit for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that the enrollee is at high risk to have unplanned 
hospitalizations and frequent emergency room visits due to their diagnoses. The Plan denied your request. The 
Plan says based on the information submitted there is no documentation that the enrollee meets the criteria for 
coverage. 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 SSBCI have been met. Medical 
records were not provided with this case. The record shows that the Plan made multiple attempts to obtain this 
information, but it was not received. Without medical records, we are unable to determine if the enrollee meets 
the criteria for coverage for SSBCI. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefit for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve intra-dialytic parenteral nutrition (IDPN). 
 
You asked the Plan to pre-approve IDPN. You say that your provider feels the requested service is medically 
necessary. The Plan denied your request. The Plan says that that the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for parenteral nutrition to be considered reasonable 
and necessary, the treating practitioner must document that enteral nutrition has been considered and ruled out, 
tried and been found ineffective, or that EN exacerbates gastrointestinal tract dysfunction. The enrollee must 
have a permanent impairment. 
 
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 IDPN. Our reviewer says that the 
coverage criteria has been met. Our physician reviewer found that you have severe protein calorie malnutrition 
and have failed counseling and protein supplementation. Therefore, intra-dialytic parenteral nutrition is 
medically reasonable and necessary for the management of your 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 IDPN have been met. Therefore, we decided that the Plan has to pre-approve 
intra-dialytic parenteral nutrition (IDPN).  
 
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: 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 SNF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to a SNF 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 87641. We decided that the Plan does not have to pay for 87798.  
 
You asked the Plan to pay for infectious agent detection (procedure codes 87641 and 87798) provided to the 
enrollee on December 18, 2021.. You say that this should be paid for. The Plan says that the billed codes are 
not supported. 
 
We decided that the Plan has to pay for 87641.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87641 is "Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique." 
 
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 for CPT 87641. Our reviewer says that the laboratory 
results show Staphylococcus Saprophyticus>ABR Methicillin>Not Detected. These are the results of testing for 
staph methicillin resistant strain. The code is supported. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
87641.  
 
We also decided that the Plan does not have to pay for 87798. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87798 is "Infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified; amplified probe technique, each organism." 
 
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 for CPT 87798. Our reviewer says that the records do 
not support 12 units of this code. There needs to be documentation of the code description for each unit, and 
this was not documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87798 have not been met. Therefore, we decided that the Plan does not have to 
pay for 87798. 
 
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.