Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel the admission to an acute rehabilitation 
facility is medically necessary. The Plan denied your request. The Plan says criteria for admission to the Acute 
Inpatient Rehabilitation setting have 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 
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. Medically necessary care can be provided in a different 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (POV) 
(K0800). 
 
You asked the Plan to pre-approve a Group 1 POV. You say that the requested POV is a medical necessity for 
you. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 Group 1 POV. Our reviewer says that 
the requested POV is not medically reasonable and necessary in this case. Our physician reviewer found that in 
2020 or 2021 it was apparently documented that you have a significant mobility deficit, and you were provided 
a Group 2 power wheelchair at that time. However, based on the medical records provided at this time, there is 
no documentation that you presently have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within 
the home, nor that such a  mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. 
 
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 Group 1 POV have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 1 standard power operated vehicle (POV) (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart (75571). 
 
You asked the Plan to pre-approve a CT scan of the heart. The Plan denied your request. The Plan says 
quantitative calcium scoring is not a covered service and is considered not medically necessary. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.  
The test at issue in this appeal, a CT scan of the heart, is being requested solely for screening purposes due to 
intermediate coronary artery disease risk. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
heart (75571).
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 you need the rehab after the surgery. The Plan 
denied your request. The Plan says the request is not medically necessary, the services you need can be 
provided safely in other settings, for example, a skilled nursing facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture reline (D5761). 
 
You asked the Plan to pre-approve the denture reline. You say that this service is medically necessary. The 
Plan denied your request. The Plan says a partial mandibular denture reline (D5761) is not covered by 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial mandibular denture reline (D5761).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee is in need of acute 
inpatient hospital admission. Medical records have been attached to prove medical necessity. The Plan denied 
your request. The Plan says the enrollee does not have more complex than expected surgery nor does she have 
any periprocedural or post procedure complication which need inpatient care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for acute inpatient hospital care is met in 
this case. Our physician reviewer found there is no documentation provided indicating that the enrollee will 
require an inpatient hospital admission for the elective procedure. Her medical conditions are stable. The 
review has determined that the record does not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one visit for dental care. 
 
You asked the Plan to pre-approve the dental service. You say that you have been seeing this dentist for at least 
five years and you do not wish to change. The Plan denied your request. The Plan says dental services from an 
out-of-network provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve one visit for 
dental care.
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 admission to an LTACH facility is 
absolutely medically necessary and will improve the enrollee's quality of life. The Plan denied your request. 
The Plan says based on Medicare guidelines, the LTACH services requested do not meet the requirements for 
approval. 
 
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 more stable and improving with current treatment and should only 
require short-term additional acute care services that can safely be administered at the current facility until 
more appropriate for a lower level of care such as home health 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture -maxillary upper arch (D5110) and 
complete denture -mandibular lower arch (D5120). 
 
You asked the Plan to pre-approve dental services. You say that the enrollee needs the requested services. The 
Plan denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Complete denture -maxillary 
upper arch (D5110) and complete denture -mandibular lower arch (D5120) are not covered under the Plans 
dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested complete denture -
maxillary upper arch (D5110) and complete denture -mandibular lower arch (D5120) are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve complete denture -
maxillary upper arch (D5110) and complete denture -mandibular lower arch (D5120).
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 the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee is 
receiving the care they need in the hospital where they are now and there is no need to transfer to the LTACH 
at this time. The enrollee can stay in the hospital until they are safe for transfer or discharge. 
 
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 acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants (D6010) for tooth #19, #20, #21, #22, #25, 
#26, #27, #28, #29, and #30. 
 
You asked the Plan to pre-approve the dental services. You say that you were told the implants would be 
covered and you would like to appeal the denial for the implants. The Plan denied your request. The Plan says 
the denial of authorization for these services is correct, because dental implants and all associated services are 
not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implants (D6010) for tooth #19, #20, #21, #22, #25, #26, #27, #28, #29, and #30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99213) with a gynecologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says you must use network providers to get your 
medical care and services. There are in-network providers available. 
 
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 
an office visit (99213) with a gynecologist 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 occlusal guard hard appliance, full arch provided on 
September 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
occlusal guard hard appliance, full arch provided on September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory surgical boot (L3260) provided July 25, 
2022. 
 
You asked the Plan to pay for foot orthotics. You say that please pay for your medical device, the boot. You are 
on a fixed income with several health issues. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the ambulatory surgical boot (L3260) 
provided July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete series of radiographic images (D0210) provided on 
June 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you the services would be 
covered. 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. This benefit includes the 
requested complete series of radiographic images (D0210) but is limited to one procedure code every five 
calendar years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you had a panoramic radiographic x-ray (D0330), therefore your benefit was exhausted on date of 
service June 20, 2019. Therefore, we decided that the Plan does not have to pay for complete series of 
radiographic images (D0210) provided on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140), intraoral radiographic images 
(D0220), and recement crown (D2920) for tooth #31 provided on April 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary, 
and you would like the Plan to cover the services that were provided. The Plan denied your request. The Plan 
says the denial of payment for these services is correct, because the oral evaluation, intraoral radiographic 
images, and recement crown are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an oral 
evaluation (D0140), intraoral radiographic images (D0220), and recement crown (D2920) for tooth #31 
provided on April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (97012) and the office visit 
(99202) provided on September 7, 2022. Additionally, the Plan does not have to waive the deductible applied 
for the chiropractic manipulative treatment (98941) provided on September 7, 2022. 
 You asked the Plan to pay for the office visit and mechanical traction therapy provided. Additionally, you 
asked the Plan to waive the deductible applied for the chiropractic manipulative treatment provided. You say 
that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The 
Plan says the office visit and the mechanical traction therapy provided are not covered benefits by the Plan or 
by Medicare. Additionally, the Plan says the deductible has been applied correctly to the chiropractic 
manipulative treatment provided. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $750 
yearly deductible. This is the amount you have to pay out-of-pocket before the Plan will begin to pay their 
share of the costs for covered medical services and you will pay your share (your copayment or coinsurance 
amount) for the rest of the calendar year. 
 
The records show that the mechanical traction therapy and the office visit provided are not covered benefits by 
the Plan or by Medicare. Additionally, the deductible in the amount of $39.31 for the chiropractic manipulative 
treatment provided has been applied correctly as the yearly deductible of $750 had not been met as of this date 
of service. Therefore, we decided that the Plan does not have to pay for the mechanical traction therapy 
(97012) and the office visit (99202) provided on September 7, 2022. Additionally, the Plan does not have to 
waive the deductible applied for the chiropractic manipulative treatment (98941) provided on September 7, 
2022.