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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's goal is to return home with family 
support after inpatient rehabilitation. You say that the enrollee will be at a high risk for falling, infection and 
readmission if they were to be discharged to a skilled nursing facility. The Plan denied your request. The Plan 
says an IRF admission is not medically necessary, and the enrollee's needs can be met in other settings. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle libre 2 continuous glucose monitor (CGM) 
system (receiver, transmitter, and sensor). 
 
You asked the Plan to pre-approve a Freestyle libre 2 continuous glucose monitor (CGM) system. You say that 
the items are medically necessary. The Plan denied your request. The Plan says the member does not use 
insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
libre 2 continuous glucose monitor (CGM) system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle libre 2 continuous glucose monitor (CGM) system (receiver, transmitter, 
and sensor).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met in other settings. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee had an episode that set them back. The 
enrollee's SNF stay was extended one week, but you do not feel one week is enough. You say the enrollee 
would benefit from additional therapy. The Plan denied your request. The Plan says the continuation of the 
SNF level of care is no longer medically necessary as the enrollee's needs can be safely met at a lower level of 
care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the typhoid vaccine (90691) provided on January 6, 2023. 
 
You asked the Plan to pay for the typhoid vaccine. You say that you were not advised this was to be paid 
through Part D. You say that you needed this vaccine to travel. You also say that this should be covered. The 
Plan denied your request. The Plan says the typhoid vaccine is not covered by Medicare or the Plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the typhoid vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the typhoid 
vaccine. Therefore, we decided that the Plan does not have to pay for the typhoid vaccine (90691) provided on 
January 6, 2023.  
 
Benefits for the typhoid vaccine 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: 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, and it is medically necessary. 
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 document does not support necessity for admission to an IRF and the complexity of 
the enrollee's nursing, rehab, and medical, needs (no combined complexity) does not require an acute hospital 
inpatient rehab stay with an interdisciplinary approach to rehabilitative care. 
While the enrollee may benefit from PT, and OT, the enrollee's rehab needs can be provided in a lower 
intensity and alternate setting such an in an SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says these are not covered items. 
 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 a pneumatic compression device (E0675, E0673).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial-upper arch (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that this should 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 24, 2022. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial-upper arch (D5213).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trans perineal placement of biodegradable material peri-
prostatic single or multiple injections including image guidance when performed (55874). 
 
You asked the Plan to pre-approve trans perineal placement of biodegradable material peri-prostatic single or 
multiple injections including image guidance when performed. You say that this is medically necessary. The 
Plan denied your request. The Plan says this 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 trans perineal placement of 
biodegradable material peri-prostatic single or multiple injections including image guidance when performed. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the records do not show that you are planning to have external beam 
radiation therapy for treatment of prostate cancer.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of trans perineal placement of biodegradable material peri-prostatic single or 
multiple injections including image guidance when performed have not been met. Therefore, we decided that 
the Plan does not have to pre-approve trans perineal placement of biodegradable material peri-prostatic single 
or multiple injections including image guidance when performed (55874).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that the enrollee has been on SSBCI benefits since 
last year. You also say the enrollee's conditions remain the same, and they should still qualify for continuation 
of these benefits. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, the records do not show that the enrollee has met 
all the required criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, heavy duty, extra wide, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type of side rails, without 
mattress (E0301). 
 
You asked the Plan to pre-approve an extra wide heavy duty hospital bed. You say that you were approved for 
a standard bed and not what you were requesting. You disagree with the denial and request reconsideration. 
The Plan denied your request. The Plan says the request does not meet the Medicare or health plan coverage 
criteria. Weight criteria is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered 
if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more 
than 350 pounds but does not exceed 600 pounds. 
 We looked at the file and Medicare rules. Medicare rules say that the requested bed is covered if you weigh 
more than 350 pounds but do not exceed 600 pounds. The records show that as of March 23, 2023, your weight 
is 285 pounds, therefore, you do not meet the weight criteria for the requested hospital bed. Based on this 
information, we decided that Medicare rules for coverage of an extra wide heavy duty hospital bed have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a hospital bed, heavy duty, extra 
wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type of side 
rails, without mattress (E0301).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says based on the 
information submitted, there is no documentation that you meet all three criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI benefits have been met. 
Medical records were not provided for this case. The records show that the Plan made multiple attempts to 
obtain this information, but it was not received. Without medical records we are unable to determine if you 
meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
device (E0730). 
 
You asked the Plan to pre-approve TENS device. You say that your doctor agrees that this is medically 
necessary. The Plan denied your request. The Plan says the records do not indicate that you have acute 
postoperative pain, or that you are part of an approved 
clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that transcutaneous electrical nerve stimulation 
(TENS) is not reasonable and necessary for the treatment of chronic low back pain (CLBP).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of TENS device have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a transcutaneous electrical nerve stimulation (TENS) device (E0730).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you were told that you were approved for 
more, and you have a chronic autoimmune disease. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Guide strips. 
 
You asked the Plan to pre-approve the Accu-Chek Guide strips. You say that the enrollee has type 2 diabetes. 
The Plan denied your request. The Plan says we dont have evidence that the coverage criteria were met. The 
Plan says that they made reasonable attempts for clarification of quantity. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Accu-Chek Guide strips have been 
met. The Plan has shown that they made reasonable attempts to obtain this information. Therefore, we decided 
that the Plan does not have to pre-approve Accu-Chek Guide strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs to have the requested 
treatment. 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 crown - porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) but 
are limited to once every five years. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered crown - porcelain/ceramic (D2740) and core buildup, including any pins when 
required (D2950) on date of service May 19, 2022; therefore, the requested item or service was exhausted on 
date of service May 19, 2022. Therefore, we decided that the Plan does not have to pre-approve crown - 
porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this should 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 2, 2021. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have really bad pains in your knees and 
care barely walk. You also say that you have diabetes, your doctor is aware of this, and you do not understand 
why you do not qualify for the SSBCI benefit. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).