Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) and was recently hospitalized. Arterial blood gas (ABG) in the hospital was 
consistent with acute-on-chronic hypercarbic respiratory failure; however, no ABG was done while the enrollee 
was stable, confirming chronic carbon dioxide retention. The records do not support that the home ventilator is 
reasonable or medically necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6111, D6110) 
 
You asked the Plan to pre-approve the dental implants. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants (D6111, D6110)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure fills a treatment gap for 
those that do not receive adequate relief from traditional conservative methods and do not have instability to 
indicate fusion is the appropriate treatment. You also say that the enrollee has tried conservative treatment 
without relief. The Plan denied your request. The Plan says the requested procedure is 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found an Intracept procedure is considered experimental and investigational. Therefore, the 
reviewer found that the requested Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omnipod 5 G6 Kit Intro and Mis Pods. 
 
You asked the Plan to pre-approve disposable insulin supplies. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the requested Omnipod disposable insulin pump system supplies are 
not a covered benefit under the enrollee's Medicare Part B plan. The enrollee does not have pharmacy benefit 
with the plan and Omnipod disposable insulin pump system is covered by the pharmacy benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omnipod 5 G6 Kit Intro 
and Mis Pods.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum-assisted socket system (VASS) (L5781). 
 
You asked the Plan to pre-approve a VASS. You say that the enrollee underwent a right transtibial amputation 
in 2011. You say that the enrollee requires a replacement vacuum pump to continue using a prosthesis safely. 
You also say that the enrollee has successfully used elevated vacuum for 11 years. The Plan denied your 
request. The Plan says the requested item is not medically necessary. The Plan also says that the requested 
VASS exceeds the enrollee's needs. 
 
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 a VASS. Our reviewer says that the 
requested VASS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested device has not been shown to be superior to other standard treatments for the medical 
condition. Therefore, the reviewer found that the requested device is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a VASS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vacuum-assisted socket system (VASS) (L5781).
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 enrollee's needs cannot be safely met by home 
health or skilled nursing. The Plan denied your request. The Plan says the enrollee does not need an intensive 
program with a team of rehabilitation doctors. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for constipation and blood in stool after recent stroke.  
He was discharged to skilled nursing. His medical problems are stable. He does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy 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 IRF care is appropriate for the enrollee. The Plan 
denied your request. The Plan says that the complexity of the enrollee's nursing, medical and rehabilitation care 
needs does not require an IRF stay and intensive physician and nursing oversight that can only be provided in 
an 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 that the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of 
rehabilitative services with regular physician evaluation. The enrollees care needs can be met at a lower level 
of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 pay for the two periodontal scalings and root planings (D4341 x2), 
resin-based composite of two surfaces (D2392), and four resin-based composites of one surface (D2391 x4) 
provided on January 20, 2022. 
 
You asked the Plan to pay for the scalings and planings and resin-based composites. You say that you were 
never informed about your coverage. You also say that you are not willing to pay for the five fillings and deep 
cleaning since you were never advised about the out-of-pocket costs. The Plan denied your request. The Plan 
says the scalings and planings are not a covered expense under your dental plan. The Plan also says that your 
resin-based composite benefit has been satisfied and the frequency limitation has been exceeded. 
 
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, periodontal scaling and root planing 
(D4341) is not among those covered under this benefit. The contract also says that restorations are limited to 
two procedure codes per calendar year. The record shows that you received seven resin-based composites on 
January 20, 2022, two of which were covered by the Plan, and your restorations benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the two periodontal scalings and root planings 
(D4341 x2), resin-based composite of two surfaces (D2392), and four resin-based composites of one surface 
(D2391 x4) provided on January 20, 2022.  
 
Your complaint about not being advised about your coverage or out-of-pocket costs for the services 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. The Plan denied your request. The Plan says the enrollee's 
condition requires further treatment in the acute hospital. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for rib fractures and pleural effusions after a fall. His 
medical problems are stable. The complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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 skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is not fully strong. The Plan denied 
your request. The Plan says the enrollee does not require daily skilled nursing or therapy in a SNF 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 SNF services. Our physician reviewer 
found that the enrollee does not require skilled nursing services provided by a skilled professional nurse. The 
records do not document the need for intravenous medications, new tube feeding, or ostomy care or daily 
complex wound care or respiratory care. Although the enrollee does require skilled therapy services, there is no 
documentation that daily skilled services are required. The records do not support that services in the assisted 
living facility 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria for admission to an IRF has not been met. 
 
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 that the clinical documentation shows that the enrollee has complex functional 
impairments however there are no active medical comorbidities specified thus would not be expected to require 
inpatient hospitalization during rehabilitation. The complexity of the enrollee's nursing, medical and rehabilitation needs documented does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient left total knee replacement (27447). 
 
 
You asked the Plan to pre-approve the outpatient procedure. You say that this surgery is very necessary. The 
enrollee is unable to perform daily activities, has no range of motion and walks with a limp and uses a cane 
daily for support. The Plan denied your request. The Plan says total left knee replacement is 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 the outpatient procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for osteoarthritis. The enrollee presented with chronic 
bilateral knee pain with the left being worse. There is intermittent sharp pain in the posterior portion of the 
knee and a constant ache in the anterior portion of the knee. However, detailed documentation is not evident 
regarding a trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. 
The enrollee is noted to have tried physical therapy and a steroid injection; however, the dates of these conservative treatments were not provided. Additionally, the enrollee has a body mass index of 45.19 
kg/m2 (with increased potential for suboptimal outcomes.) There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested outpatient left total knee replacement (CPT 27447), 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 the outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve outpatient left total knee replacement (27447).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided May 16, 2022, to June 14, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was received by the Plan was submitted incorrectly. The admit date listed on the NOA 
was December 17, 2021. A date of admission matching the from date on the first date of care in an admission. 
As the NOA has incorrect information, no payment can be made on this claim. Therefore, we decided that the 
Plan does not have to pay for the home health services provided May 16, 2022, to June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (A9270, 0202U) billed for date of service 
December 5, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code A9270 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code A9270 is non-covered. Additionally, the requested respiratory panel of 6 or more pathogens is 
non-covered per LCD L37713. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the services (A9270, 
0202U) billed for date of service December 5, 2021.
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 enrollee is at risk for falls and readmission to 
acute care. The Plan denied your request. The Plan says the enrollee does not have complex medical, or therapy 
needs. 
 
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 physician reviewer found 
that the enrollee was hospitalized for influenza A with hypoxic respiratory failure. The clinical documentation 
shows that the enrollee has functional impairments.  However, there are no complex functional impairments specified. The enrollee would not be expected to 
require intense therapy or interdisciplinary team management of rehabilitation in an IRF setting. There are no 
active medical comorbidities documented thus would not be expected to require inpatient hospitalization during 
rehabilitation. The complexity of the enrollees nursing, medical and rehabilitation needs documented does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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 pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) provided June 9, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the prescribing physician 
recommends an extended lifetime use of equipment as they are diagnosed with chronic pain and compromised 
mobility without the option for surgical correction. The Plan denied your request. The Plan says evidence of 
misrepresented services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order for the supplies provided in this case. Specifically, the Plan 
made outreach to the ordering provider indicated on the claim and verified that they have not seen this enrollee 
and therefore, there was no order made for this enrollee. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for the electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) (A4595) provided June 9, 
2022.