Persius/hicric huggingface dataset:
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 currently undergoing treatment at an ACH for complications related to 
a feeding tube. The enrollee arrived with a tracheotomy from a prior hospitalization. The enrollee is not on a 
ventilator, tolerating a tracheotomy collar. There is no evidence that the enrollee requires services that are not 
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing LTC 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home portable ventilator (E0466). 
 
You asked the Plan to pre-approve a home portable ventilator. You say that the requested ventilator is 
medically necessary. The Plan denied your request. The Plan says the requested ventilator does not meet 
criteria. 
 
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 a home portable ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you do not meet 
Medicare criteria for a ventilator at home. There is no CO2 retention on an ABG done during acute illness. 
Although there are listed diagnoses of asthma and COPD, the primary problems appear to be severe 
tracheobronchomalacia and bronchiolitis. Pulmonary function tests show mild restrictive disease, without 
obstruction. There is no thoracic restrictive disease or generalized neuromuscular disease. 
 
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 home portable ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home portable ventilator (E0466).
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an 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 based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vraylar 1.5mg tablets. 
 
You asked the Plan to pre-approve Vraylar. You say that Vraylar is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical 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 Vraylar 1.5mg tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on January 14, 2022. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not billed. 
 
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, we have confirmed that code 12031 is a column II code to column I code 17110. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the wound care 
services provided on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental 
gradiant appliance (E0673), provided on October 19, 2021. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says this device is not covered for the prevention of deep 
vein thrombosis during or after surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) and segmental gradiant appliance (E0673), provided on 
October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum surgery (D4266), an implant placement (D6010), 
an implant (D6011), a custom abutment (D6057), an abutment supported crown (D6059), a bone graft (D6104), 
collection and application of blood (D7921), and a bone replacement graft (D7953) provided by a contracted 
provider. 
 
You asked the Plan to pre-approve gum surgery, an implant placement, an implant, a custom abutment, an 
abutment supported crown, a bone graft, collection and application of blood, and a bone replacement graft. You 
say that you would like the Plan to approve these services. The Plan denied your request. The Plan says the 
requested dental services are not covered. 
 
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 gum 
surgery (D4266), an implant placement (D6010), an implant (D6011), a custom abutment (D6057), an 
abutment supported crown (D6059), a bone graft (D6104), collection and application of blood (D7921), and a 
bone replacement graft (D7953) provided by a contracted provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for kyphoplasty surgery provided on November 
4, 2021. 
 
You asked the Plan to waive the deductible for kyphoplasty surgery. You say that you received a bill for the 
procedure and had the same procedure in July and was not charged. The Plan denied your request. The Plan 
says the deductible applied correctly 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1500 deductible which applies to outpatient surgery.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient hospital 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $1500 deductible which applies outpatient surgery. This cost sharing is a contractual obligation that had not 
been met at the time kyphoplasty surgery was received on November 4, 2021. The allowed amount of this 
claim is $1008.36, so you are responsible for a deductible amount of $1008.36 Therefore, we decided that the 
Plan does not have to waive the deductible for kyphoplasty surgery provided on November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (81455) 
provided June 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this course of treatment is prudent and 
necessary in order to improve, and ultimately maintain the health of the enrollee. The Plan denied your request. 
The Plan says Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic 
decision-making in the clinical management of the patient and will be denied automatically as 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the targeted genomic sequence analysis panel (81455) provided June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #26. 
 
You asked the Plan to pre-approve the crown. You say that your doctor said you have to have 4 crowns 
provided at the same time. You also say that you have not exceeded the annual $5,000 dental benefit 
maximum. The Plan denied your request. The Plan says you have already exhausted your annual benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a maximum limit of up 
to $5,000 per year for the listed supplemental comprehensive dental services. The record shows that you were 
approved to receive three crowns (D2750 x3), four retainer crowns (D6750 x4), and three pontics (D6240 x3) 
which totals the amount of $5,115.00, and your annual maximum benefit will have been exhausted once these 
services are rendered. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for 
tooth #26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Lantus Solostar provided on October 14, 2021. 
 
You asked the Plan to pay for Lantus Solostar. You say that you would like to be reimbursed for the cost of this 
drug. The Plan denied your request. The Plan says insulin is not covered unless it is used in a pump. 
 
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 pay for Lantus Solostar provided on 
October 14, 2021.  
 Benefits for Lantus Solostar may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve additional OT visits. You say that the services are medically necessary. The 
Plan denied your request. The Plan says additional OT visits 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 additional OT visits. 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 provided documentation indicates that the enrollee has had prior 
therapy and the documentation does not reveal that the enrollee requires the unique skills of a professional 
therapist to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist, or by or under the supervision of a therapist. The reviewer found that the requested services 
are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified 
therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current 
condition or to prevent or slow further deterioration. The reviewer found that the enrollee has been instruction 
in an independent home program. Therefore, the reviewer found that ongoing skilled therapy 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 additional OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional occupational therapy (OT) visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging (78452) 
provided on July 29, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $495 
copayment for nuclear medicine services rendered at an in-network outpatient hospital.  
 
 You have been asked to pay a $495 copayment for the nuclear medicine service rendered at an in-network 
outpatient hospital. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the myocardial perfusion 
imaging (78452) provided on July 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial profusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve SPECT testing. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the records do not show that you have any of the covered indications for 
stress testing with cardiac imaging. 
 
The Plan follows Medicare rules. Medicare rules say that SPECT is considered medically necessary for specific 
situations. 
 
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 SPECT testing. Our reviewer says that 
the SPECT testing is not medically necessary. Our physician reviewer found there was no indication or 
description in the provided documentation that prevented the enrollee from having an exercise stress test. There 
were no exceptions to the criteria that had been met. Therefore, the reviewer found that this request for stress 
test with myocardial perfusion will be considered 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 SPECT testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial profusion imaging, tomographic (SPECT) (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99153) provided July 26, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this service is not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a PC/TC 
Modifier Status of 3. This service is not separately payable when performed in a facility setting. The service 
was billed with place of service 21. Based on this information, we decided that Medicare rules for coverage of 
the physician services have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for physician services (99153) provided July 26, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three bone replacement grafts of the first sites in 
quadrant (D4263 x3), two bone grafts of each additional quadrant site (D4264 x2), five guided tissue 
regenerations (D4266 x5), and four free soft tissue graft procedures (D4277 x4). 
 
You asked the Plan to pre-approve the bone replacement grafts, guided tissue regenerations, and free soft tissue 
graft procedures. You say that you need to have these procedures done but the cost is very high. The Plan 
denied your request. The Plan says these services are not covered by 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 pre-approve three 
bone replacement grafts of the first sites in quadrant (D4263 x3), two bone grafts of each additional quadrant 
site (D4264 x2), five guided tissue regenerations (D4266 x5), and four free soft tissue graft procedures (D4277 
x4).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the clinical information provided 
supports the need for inpatient psychiatric care. The Plan denied your request. The Plan says the guidelines for 
coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted 
to the acute inpatient psychiatric hospitalization on May 14, 2022, with Schizoaffective Disorder Unspecified. 
Based upon review the records provided it was not expected this enrollee would improve in a reasonable period 
of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or 
visual hallucinations and no aggressive behaviors. This patient was paranoid but much less than on admission. 
It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient 
level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or 
homicidal thoughts, hallucinations or aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
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 continuous glucose monitor (CGM). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for a continuous glucose monitor (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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of continuous glucose monitor (CGM) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).