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 the enrollee will benefit from IRF care. The Plan 
denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the 
requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 dental services provided on March 16, 2021, and April 6, 
2021. 
 
You asked the Plan to pay for the dental services. You say that you believe you first filed this paperwork in 
January. The Plan denied your request. The Plan says these claims were not filed timely so they cannot be 
considered for payment. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until April 18, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for dental services provided on March 16, 2021, and April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve benign lesion removal. 
 
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. Medicare rules say that benign lesion removal is covered when specific 
criteria are met. 
 
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 records indicate that the enrollee 
has two lesions on his face at 2.5 millimeters in size. No further information is provided. The submitted records 
are insufficient to determine if the criteria for coverage are satisfied or if the services are being requested for 
cosmetic purposes. The lesion removal is therefore not 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 benign lesion removal.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 00812 provided on January 14, 
2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 00812 is not supported in the medical record. Specifically, this code was billed with an 
invalid modifier. Based on this information, we decided that Medicare rules for coverage of the anesthesia 
services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
coded 00812 provided on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair lift mechanism (E0627, S5199). 
 
You asked the Plan to pre-approve a chair lift. You say that due to difficulties with mobility and transportation, 
you had not been able to evaluate the enrollee in the office for quite some time. Now that she has been able to 
come in for a visit, it is apparent that she has had decline in her condition. The Plan denied your request. The 
Plan says the enrollee did not meet all the guidelines for a seat lift mechanism. The enrollee was previously 
able to get up from her recliner and was also able to stand up from a regular chair in the clinic room. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a chair lift have not been met. Specifically, the enrollee does not meet all Medicare guidelines for a 
chair lift mechanism. Therefore, we decided that the Plan does not have to pre-approve a chair lift mechanism 
(E0627, S5199).
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 do not agee with this denial. The Plan denied 
your request. The Plan says you do not meet IRF criteria and you can be managed at a lower level of care. 
 
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation doesnt support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain his functional status.  You can receive further 
services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies for a continuous glucose monitor (CGM) provided 
on January 15, 2022. 
 
You asked the Plan to pay for CGM supplies. You say that the requested supplies were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
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 proof of delivery for the supplies provided in this case. 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 supplies for a continuous glucose monitor (CGM) provided on 
January 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 
87798 provided on September 21, 2021. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid services. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services provided are not a covered 
benefit. 
 
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 infectious agent detection by nucleic acid services test at issue in this appeal was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87798 provided 
on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom abutment (D6057) and crown (D6058) provided 
on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you expected the Plan to cover at least half for 
the services. The Plan denied your request. The Plan says the services you received are not covered under your 
supplemental 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 pay for the 
custom abutment (D6057) and crown (D6058) provided on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
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. Medicare rules say that RFA is covered when specific criteria are met. 
 
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 low back pain. 
She has been treated with medical therapy including opiates and underwent a left lumbar radiofrequency 
ablation (RFA) at L3-S1 performed on June 13, 2019 which provided 50 percent pain relief for two years. She 
has not had at least two recent medial branch blocks (MBBs) providing at least 80 percent sustained relief. The 
RFA is therefore not 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 radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to provide additional payment for the crowns - porcelain fused to predominantly 
base metal (D2751) provided January 8, 2021. 
 
You asked the Plan to provide additional payment for the crowns. You say that your crowns were pre-approved 
and should be covered. The Plan denied your request. The Plan says that your full $1,000 dental allowance has 
been applied to your claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided the correct Evidence of Coverage (EOC) 
showing that the enrollee has a $1,000 allowance. Without the correct plan documentation to review, we are 
unable to verify that the enrollee has a dental allowance which has been exceeded. Therefore, we decided that 
the Plan has to provide additional payment for the crowns - porcelain fused to predominantly base metal 
(D2751) provided January 8, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics received on March 16, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you disagree with the Plan's denial. 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 foot orthotics received on March 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120) to be rendered by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the periodic oral evaluation. 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 a periodic 
oral evaluation (D0120) to be rendered by an out-of-network (OON) provider.
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 LTACH is the appropriate level of care 
to manage the enrollee's ongoing needs. The Plan denied your request. The Plan says criteria for admission to 
the LTACH have not been met. 
 
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 appears to be stable and improving and should only require short-term 
additional acute care hospital services that can be safely administered at the current facility until more 
appropriate for a lower level of 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: 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
  
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 pay for the periapical images (D0220 and D0230) provided on May 
19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the same treatment was performed the year 
before and was covered under your plan. The Plan denied your request. The Plan says the services you received 
are not covered under your supplemental 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 pay for the 
periapical images (D0220 and D0230) provided on May 19, 2022.
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 LTACH admission is medically 
necessary because the patient requires a multi-disciplinary approach for an extended period of time. The Plan 
denied your request. The Plan says LTACH admission is not medically necessary. The patient's medical needs 
are being met in the current acute setting. The LTACH would add no additional services. With additional time 
in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be 
determined. 
 
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 patient is a 62 year old male with chronic respiratory failure on CPAP at home 
who was admitted to the acute care hospital with acute on chronic respiratory failure due to mucous plugging, 
pneumonia, non-ST-elevation myocardial infarction type II, large stage IV decubitus ulcer, deep vein 
thromboses, urinary tract infection, wound debridement, wound VAC, IV antibiotics, bronchoscopy, and mechanical ventilation support. Recent notes describe the patient as now tolerating 5L/m oxygen via nasal 
cannula during the day and CPAP at night, and has completed antibiotic course but still using wound VAC. 
The patient appears to be more stable and improving and should only require short-term additional acute care 
hospital services that can be safely administered at the current facility until more stable and appropriate for a 
lower level of care. The patient does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the patient requires that are not already available and 
covered 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.