Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system. 
 
You asked the Plan to pre-approve the requested device. You say that the device is well-suited for those with 
bronchiectasis  The Plan denied your request. The Plan says there is inadequate evidence of the benefit in the 
outpatient or home setting.  
 
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 the requested device. Our physician 
reviewer found that the enrollee has bronchiectasis and cavitary lung disease, and pulmonary infection with 
mycobacterium avium complex (MAC). The records note that the enrollee has not been consistent using an 
Acapella device for airways clearance and has not tried a chest wall oscillation device. The Volara device has 3 
components: airway oscillation, positive end expiratory pressure, and nebulization. The device has not been 
studied enough to show benefit in the treatment of any chronic lung disease. There is inadequate evidence that 
this device is as, or more, effective than other devices in achieving airways clearance. Therefore, the request 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 the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Volara system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service November 
22, 2021.  
 
You asked the Plan to pay for procedure code 99232. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 
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 99232 
is a column II code to column I code 99233 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99232 billed for date of service November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
The elements of the coverage criteria are not satisfied. The requested service cannot be 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the vision services provided on December 
19, 2022. 
 
You asked the Plan to waive the deductible for the vision services. You say that this was a routine eye exam 
and should be covered. The Plan denied your request. The Plan says this cost sharing was charged 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 $750 deductible which applies to out-of-network vision care. Your 
contract with the Plan also says that you must pay a $50 copayment after meeting the deductible for out-of-
network vision services. 
 
The records show that a test to determine if prescription eye wear is needed (code 92015) was provided. The 
item or service you asked the Plan to waive the deductible for falls within the vision services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to out-of-network vision care. This cost sharing is a contractual obligation that had not been met at the 
time the vision services was received on December 19, 2022. Therefore, we decided that the Plan does not have 
to waive the deductible for the vision services provided on December 19, 2022.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 show any acute complex functional impairments or active 
medical comorbidities; Thus, would not be expected to require an inpatient hospitalization with an 
interdisciplinary approach to rehabilitation care. 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: 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 intensive skilled 
therapy in order to progress back to their prior level of functioning. The Plan denied your request. The Plan 
says the enrollee does not meet the Medicare criteria for admission to an IRF.  
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical removal of erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) provided on February 2, 2023. 
 
You asked the Plan to pay for surgical removal of erupted tooth. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 surgical 
removal of erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on February 2, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a split stability chair. 
 
You asked the Plan to pre-approve a split stability chair. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a split stability chair.
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 admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with metal crown tooth 23 (D2751). 
 
You asked the Plan to pre-approve white glass with metal crown. You say that this is medically necessary. The 
Plan denied your request. The Plan says your tooth has to have a lot of tooth missing from a cavity or have a lot 
of damage from being broken and it can no longer be fixed with a filling. The x-rays your dentist sent show a 
crown is not needed to fix your tooth. 
 
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. The Plan covers white glass 
with metal crown when the services are medically necessary and reasonable.  
 
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 white glass with metal crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found a tooth must show 
significant coronal breakdown due to caries or fracture to meet the criteria for coverage for a crown restoration. 
Due to the poor quality of the radiographs, a determination could not be made if there was significant coronal 
breakdown of tooth #23 to warrant a crown restoration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of white glass with metal crown have not been met. Therefore, we decided that the 
Plan does not have to pre-approve white glass with metal crown tooth 23 (D2751).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Alphatec Bridgepoint interspinous device to L4 to 
L5. 
 
You asked the Plan to pre-approve the Alphatec Bridgepoint interspinous device to L4 to L5. You say that the 
enrollee is at a nine out of ten-pain level and interfering with daily living. The Plan denied your request. The 
Plan says the Alphatec Bridgepoint interspinous device to L4 to L5 because the effectiveness of the lumbar 
stenosis with neurogenic claudication have not been demonstrated in the peer-reviewed literature. 
 
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 the Alphatec Bridgepoint interspinous 
device to L4 to L5. Our reviewer says that the requested surgery is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Alphatec Bridgeport device is experimental, and more literature is needed to show safety and efficacy of interspinous devices. 
 
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 Alphatec Bridgepoint interspinous device to L4 to L5. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Alphatec Bridgepoint interspinous device 
to L4 to L5.
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 is medically stable to transfer The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
Inpatient Rehabilitation 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing care rendered on August 1, 2022. 
 
You asked the Plan to pay for the services. You say that the services were provided in good faith. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for nursing care rendered on August 1, 2022.
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 admission to a SNF is medically necessary. The 
Plan denied your request. The Plan says you do not meet the Medicare criteria for SNF 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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: 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 would like to appeal because your 
attestation for utilities was denied. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that the request of five home health skilled 
nursing visits are medically necessary. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation does not show any acute clinical status changes, medication changes, or plan of care update. 
The records do not show that skilled nursing services would be required to improve the enrollee's condition or 
to maintain the patient's condition and/or prevent deterioration. Therefore, five additional home health skilled 
nursing visits are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five home health skilled nursing visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and will 
benefit from a transfer to an LTACH. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee's needs can be met in the current hospital setting.  
 
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 that the enrollee is still unstable and requires short-term additional acute care hospital 
services that can be safely provided at the current facility until they are more stable and ready for 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.