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

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950)
or pay more for the crown (D2740) provided on September 7, 2021.
You asked the Plan to pay for the core buildup and to pay more for the crown. You say that at the time you
were told you needed a crown you were also advised that you would not have to pay anything. You also say
that you live on a fixed income and do not have any extra money. The Plan denied your request. The Plan says
the core buildup is not a covered expense under your dental plan. The Plan also says that your dental maximum
has been met, and you did not contact the Plan prior to this date of service to verify benefits and provider
eligibility.
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, core buildup, including any pins when
required (D2950) is not among those covered under this benefit. The contract says that the Plan offers a $1,000
annual dental benefit maximum. The record shows that you met the annual maximum benefit while processing
this claim for the September 7, 2021 date of service and your annual maximum benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required
(D2950) or pay more for the crown (D2740) provided on September 7, 2021.
Your complaint about being misinformed by the provider's office is not a valid appeal for medical coverage.
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to
make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission.
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee was admitted for gouty arthropathy. Medical problems are stable. There are no complex nursing or
rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care.
The enrollee was admitted for a below the knee amputation and was discharged to skilled nursing on February
4, 2022, then left the skilled nursing facility against medical advice. Medical problems are stable. There are no
complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/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 inpatient rehabilitation facility (IRF) admission and services.
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 the services can be safely received in a different setting.
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
daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage.
You do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to
be required to establish a maintenance program or to prevent deterioration 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 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: 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 LTACH services are medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for
coverage of the LTACH services.
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 while the enrollee continues to receive acute care services, and these have not been
denied. The medical record does not indicate that the enrollee requires services that she is not currently
receiving but that would be available at the LTACH 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued SNF services. You say that the additional services are medically
necessary. The Plan denied your request. The Plan says the continued SNF services are 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 continued SNF services. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the reviewer found that the
enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled
therapy needs. The reviewer also found that 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 continued SNF services have not been met. Specifically, the file shows that the
enrollee does not require daily skilled services. Therefore, we decided that the Plan does not have to pre-
approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lymphedema pump and accessories to be provided
by an out-of-network (OON) provider.
You asked the Plan to pre-approve the lymphedema pump and accessories. You say that you would like
reconsideration because the requested pump is medically necessary. The Plan denied your request. The Plan
says there are in-network suppliers available to provide the requested pump.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the lymphedema pump and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extraction (D7140) and surgical extraction
(D7210) provided on September 17, 2021.
You asked the Plan to pay for the extractions. You say that for over 10 years the Plan has not paid one dollar
for your dental expenses. You also say that you are on a very fixed income. The Plan denied your request. The
Plan says your $1,000 benefit maximum had been met prior to processing this claim.
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 Plan offers a $1,000 annual dental
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. The record shows that you met the annual
maximum benefit on August 5, 2021 and your annual maximum benefit has been exhausted. Therefore, we
decided that the Plan does not have to pay for the simple extraction (D7140) and surgical extraction (D7210)
provided on September 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system.. The Plan denied your request. The Plan says
this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and
power standing feature (E2301) are non-covered because they are not primarily medical in nature.
We looked at the file and Medicare rules. Per LCA A52504, the requested power seat feature is not covered.
Based on this information, we decided that Medicare rules for coverage of a power seat elevation system. have
not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system
(E2300).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits.
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 Medicare pays for medically necessary outpatient
therapy.
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
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and
effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has
had prior therapy and the records do not demonstrate that the ongoing unique skills of a professional therapist
are required to safely and effectively provide treatment, that the services can be safely and effectively
performed only by a therapist, or for physical therapy, by or under the supervision of a therapist beyond what
was approved by the health plan. The enrollee has been instructed in a home exercise program. The requested
services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a
qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current
condition or to prevent or slow further deterioration.
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 10 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays and nerve treatments provided from July 23, 2021,
to September 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the x-rays and nerve treatments. You say that when you signed up with this plan
you were told that you had $2,000.00 per year for dental work, and were not advised that it had to be provided
in-network. You also say that there are no in-network providers for root canals. The Plan denied your request.
The Plan says non-emergency services provided by an OON provider are not available with this dental plan.
The Plan also says that the Plan did not refer you to the OON providers you were treated by.
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 requested items or services are not
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the x-rays
and nerve treatments provided from July 23, 2021, to September 9, 2021 by an out-of-network (OON)
provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve a Zephyr bronchoscopic endobronchial valve placement (EBV).
You asked the Plan to pre-approve a Zephyr bronchoscopic endobronchial valve placement. You say that the
requested service is medically necessary. The Plan denied your request. The Plan says that the requested
service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
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 Zephyr bronchoscopic endobronchial
valve placement. Our physician finds that inpatient bronchoscopic placement of EBV is reasonable and
medically necessary for this patient. EBV is no longer considered investigational. Our physician also found that
this member meets criteria for age, lung function and complete fissures by imaging. She has completed
pulmonary rehab in the recent past. EBV must be performed as an inpatient because of the risk of
pneumothorax, which can be life threatening and requires emergent treatment.
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 Zephyr bronchoscopic endobronchial valve placement have been met.
Therefore, we decided that the Plan has to pre-approve a Zephyr bronchoscopic endobronchial valve placement
(EBV).
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 a skilled nursing facility (SNF) admission.
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 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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital on
February 6, 2022 with weakness and low blood pressure (hypotension). The therapy note dated February 11,
2022 states that you need assistance to walk 100 feet using a walker and for transfers. You have no skilled
nursing needs. You do not require skilled therapy on a daily basis. As a practical matter, you do not require the
necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for acute kidney injury and a fall.
Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the
requested SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet
Medicare criteria for coverage of the requested SNF services.
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 SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found while it would be reasonable for you
to receive therapy following your hip fracture and repair, you are not currently medically able to do so.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve the Skilled Nursing Facility (SNF) services.