Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for Outpatient Hospital Services provided on November 10, 2022 to 
November 11, 2022. 
 
You asked the Plan to pay for the Outpatient Hospital Services. You say that these services were pre-approved 
and medically necessary. The Plan denied your request. The Plan says that the services at issue are not eligible 
for coverage. 
 
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. The plan did not fully articulate the reason for the denial. It is not clear from the 
documentation provided which services specifically are not covered. The documentation provided does not 
note specifically what drugs are being denied, so it cannot be determined if they are covered or not. The plan 
did not clearly cite the rule or policy used to make their determination. Therefore, we decided that the Plan has 
to pay for Outpatient Hospital Services provided on November 10, 2022 to November 11, 2022.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that physical therapy is helping, and you 
would like to move along as you did prior to your injury. The Plan denied your request. The Plan says your 
request for additional physical therapy is denied as 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 the therapy services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the Plan. You have had prior therapy 
and the documentation does not reveal that you require 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. You have had instruction in a home program. 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 your current 
condition or to prevent or slow further deterioration. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.
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 services are medically necessary for the enrollee 
to return to prior level of function. The Plan denied your request. The Plan says the enrollee's needs can safely 
be met at a lower level of care such as a skilled nursing facility or home with home health services. 
 
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 enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a swallowing function x-ray (CPT 74230) and an upper 
gastrointestinal tract x-ray (CPT 74240) provided on October 11, 2022. 
 
You asked the Plan to pay for a swallowing function x-ray (CPT 74230) and an upper gastrointestinal tract 
x-ray (CPT 74240). You say that the services were medically necessary. The Plan denied your request. The 
Plan says the services were performed at a nursing home (via mobile van/portable x-ray), which are denied as 
an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a swallowing function x-ray (CPT 74230) and an upper gastrointestinal tract x-ray (CPT 74240) 
have not been met. Therefore, we decided that the Plan does not have to pay for a swallowing function x-ray 
(CPT 74230) and an upper gastrointestinal tract x-ray (CPT 74240) provided on October 11, 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 the services are medically necessary for 
the enrollee's care needs. The Plan denied your request. The Plan says the enrollee can remain in the current 
acute care location until such time no further acute level care is needed. 
 
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 where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a save and sustainable discharge. The Plan 
denied your request. The Plan says the requested IRF admission is not medically necessary. 
 
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. The 
enrollee has a history of Sjogren's disease, osteoarthritis, and rheumatoid arthritis and is living at home with 
vertigo and frequent falls. The enrollees medical problems are stable, and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While enrollee may have a 
need for physical therapy and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (S9999) on a walker purchased on October 11, 
2022. 
 
You asked the Plan to pay for the sales tax. You say that the service should be covered. The Plan denied your 
request. The Plan says sales tax is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales 
tax. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax (S9999) on a walker purchased on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal dental implants (21248, 21249 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says these services are not covered by Medicare or 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. Additionally, these procedures are not one of the Medicare covered 
dental services covered under the enrollees medical benefit. Therefore, we decided that the Plan does not have 
to pre-approve endosteal dental implants (21248, 21249 x 3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair (K0824) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you have been waiting months to receive 
your wheelchair. The in-network provider is refusing to coordinate services. The Plan denied your request. The 
Plan says you must use in-network providers within your plans service area to get medical care and services. 
There is an available in-network supplier with the plan. 
 
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 
a group 2 heavy duty power wheelchair (K0824) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the patient's needs can be met with a BiLevel Positive 
Airway Pressure (BiPAP) device with average volume-assured pressure support (AVAPS) 
 
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 ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the enrollee is a 61-year-old 
woman with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea syndrome (OSAS). 
Submitted pulmonary evaluation includes arterial blood gas analysis (ABG) showing hypercarbia (pH 
7.41,PaCO2 53, and PaO2 67) and formal polysomnography (PSG) shows severe obstructive sleep apnea 
syndrome (OSAS) with an apnea-hypopnea index (AHI) of 68.7 events per hour. Pulmonary function testing 
(PFT) data is not submitted; however, the provider describes them as showing "severe to very severe 
obstruction." There is no evidence to support recent hospital admission. The review has determined that this 
patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure 
consequent to chronic obstructive pulmonary disease. The documentation in the medical record does not 
support that the ventilator at issue is medically necessary and reasonable for this patient. The patient's needs 
can be met with a BiLevel Positive Airway Pressure (BiPAP) device with average volume-assured pressure 
support (AVAPS). 
 
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 ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 record shows that the Plan attempted 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: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 1 additional physical therapy visit . We decided that the Plan does 
not have to pre-approve 11 additional physical therapy visits. 
 
You asked the Plan to pre-approve 12 additional physical therapy visit. You say that you need additional 
physical therapy visits to help continue with gaining your strength back. The Plan says that 12 additional 
physical therapy visits are not medically necessary.  
 
We decided that the Plan has to pre-approve 1 additional physical therapy visit .  
 
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 the therapy services. Our reviewer says 
that 1 additional physical therapy visit is medically necessary. Our physician reviewer found that a final visit, 
one, after your orthopedic follow-up to review strength training guidelines is medically reasonable. 
 
 Therefore, we decided that the Plan has to pre-approve 1 additional physical therapy visit .  
 
We also decided that the Plan does not have to pre-approve 11 additional physical therapy visits. 
 
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 the therapy services. Our reviewer says 
that 11 additional physical therapy visit is not medically necessary. Our physician reviewer found that you have 
an effective treatment program in place and can continue with a home exercise program. 
 
 Therefore, we decided that the Plan does not have to pre-approve 11 additional physical therapy visits. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for percutaneous transluminal coronary lithotripsy (PCTL) 
(procedure code 0715T) rendered on October 4, 2022. 
 
You asked the Plan to pay for the surgery. You say that this procedure was medically necessary. The Plan 
denied your request. The Plan says a service or supply furnished by a particular provider is covered if the plan 
determines that it is appropriate for diagnosis, care or treatment of the disease or injury. 
 
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 pay for the surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at issue is the medical appropriateness and necessity of PTCL, also known as shockwave 
lithotripsy, in managing this patients coronary artery disease. While clinical studies led to Food and Drug Administration (FDA) approval several years ago, PTCL remains the subject of multiple studies examining 
long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until 
such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At 
the current time, this surgery would not be medically necessary in this patient. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pay for percutaneous transluminal coronary lithotripsy (PCTL) (procedure code 0715T) rendered on 
October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), core buildup (D2950), intraorifice 
barrier (D3911), guided tissue regeneration (D4266), unspecified periodontal procedure (D4999), surgical 
placement of implant body (D6010), pontic (D6245), retainer crown (D6740), bone replacement graft for ridge 
preservation (D7953) and nitrous oxide (D9230). 
 
You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain due to an infection. 
You have an ulcer in your mouth and are afraid that this could case more health issues. The Plan denied your 
request. The Plan says these services are not covered by the Plan's 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 
crown (D2740), core buildup (D2950), intraorifice barrier (D3911), guided tissue regeneration (D4266), 
unspecified periodontal procedure (D4999), surgical placement of implant body (D6010), pontic (D6245), 
retainer crown (D6740), bone replacement graft for ridge preservation (D7953) and nitrous oxide (D9230).