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 would benefit from admission to an IRF 
where they will be seen by a physical medicine and rehabilitation physician, with the assistance of internal 
medicine and neurology for additional oversight. The Plan denied your request. The Plan says an 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 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 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 needs both rehab and medical 
management. You say that the enrollee will not recieve the same level of care or independence in a skilled 
nursing facility. The Plan denied your request. The Plan says an 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 enrollee's nursing, medical and rehabilitation can be 
provided in a lower level of care and 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM).  
You asked the Plan to pre-approve these services. You say that it is difficult for you to check your blood sugar 
by pricking your hand. The Plan denied your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the you do not treat with insulin or 
have a history of hypoglycemia (low blood sugar). 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 a Dexcom continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on July 19, 2023. 
 
You asked the Plan to pay for the shingles vaccine. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the vaccination codes were denied as they are not 
covered under your part C benefits, but they are covered under your part D benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles 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 shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on July 19, 
2023.  
 
Benefits for the shingles 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for tomographic (SPECT) myocardial perfusion imaging provided on 
March 28, 2023. 
 
You asked the Plan to pay for tomographic (SPECT) myocardial perfusion imaging. The Plan denied your 
request. The Plan says that no authorization was obtained for this service at the time it was rendered to the 
member. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee received the tomographic (SPECT) myocardial perfusion imaging by a contract provider. The file 
does not show that the Plan provided notice that tomographic (SPECT) myocardial perfusion imaging would 
not be covered prior to the services being rendered. Under Medicare rules, this means tomographic (SPECT) 
myocardial perfusion imaging is considered approved by the Plan. Therefore, we decided that the Plan has to 
pay for tomographic (SPECT) myocardial perfusion imaging provided on March 28, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for part D vaccines provided on April 17, 2023. 
 
You asked the Plan to pay for part D vaccines. You say that your vaccines should be covered under the Part C 
coverage. The Plan denied your request. The Plan says the vaccines are part D drugs and do not meet Medicare 
Part B coverage rules. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide part D vaccines. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to part D vaccines. 
Therefore, we decided that the Plan does not have to pay for part D vaccines provided on April 17, 2023.  
 
Benefits for part D vaccines 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM system. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 2 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an OTC COVID-19 test provided on June 26, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. The Plan denied your request. The Plan says OTC 
COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022 and continues until the 
COVID-19 public health emergency (PHE) ends, people with Medicare Part B can get up to eight free over-
the-counter tests for the month of April any time before April 30th and can then get another set of eight free 
over-the-counter tests during each subsequent calendar month through the end of the COVID-19 PHE. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OTC COVID-19 test have not been met. Therefore, we decided that the Plan does not have to 
pay for an OTC COVID-19 test provided on June 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopic sleeve gastrectomy. 
 
You asked the Plan to pre-approve laparoscopic sleeve gastrectomy. You say that laparoscopic sleeve 
gastrectomy is medically necessary. The Plan denied your request. The Plan says the notes provided on appeal 
do not show a follow up report from the psychiatrist showing that the enrollee improved enough to proceed with this surgery.  
 
The Plan follows Medicare rules. Medicare rules say that laparoscopic sleeve gastrectomy is covered when the 
criteria listed in the Medicare rules section of this decision 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 laparoscopic sleeve gastrectomy. Our 
reviewer says that laparoscopic sleeve gastrectomy is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee with class 3 obesity and weight-related comorbid conditions. 
The enrollee underwent a psychiatric evaluation as part of her bariatric workup and was notably not cleared for 
surgery because of significant untreated/under-treated psychiatric comorbidities. There is no subsequent 
follow-up to suggest that these issues have been addressed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laparoscopic sleeve gastrectomy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve laparoscopic sleeve gastrectomy.
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 enrollee currently meets acute 
LTACH admission criteria under CMS guidelines. The Plan denied your request. The Plan says the enrollee's 
condition does not meet all the requirements for inpatient rehabilitation admission. The Plan says services may 
be provided in another setting, an acute rehabilitation facility, skilled nursing facility, nursing facility, 
outpatient setting or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic radiosurgery services. 
 
You asked the Plan to pre-approve stereotactic radiosurgery services. You say that it is medically necessary. 
The Plan denied your request. The Plan says it 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 stereotactic radiosurgery services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no specific standard of care, stereotactic body radiotherapy would 
not be an accepted standard 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 stereotactic radiosurgery services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve stereotactic radiosurgery 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 requires 24/7 nursing care with 
physician oversight for close monitoring and intervention of pneumonia, and congestive heart failure 
exacerbation. You say the enrollee also requires ongoing consultation by internal medicine for management of 
multiple comorbidities and consultation by pulmonary and cardiology for management of pneumonia and 
chronic heart failure. The Plan denied your request. The Plan says an 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional trips for routine transportation. 
 
You asked the Plan to pre-approve additional transportation.. The Plan denied your request. The Plan says you 
have exceeded you benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 10 additional trips for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite - one surface, anterior 
(D2330)  50% coinsurance provided on July 18, 2023. 
 You asked the Plan to pay more for the resin-based composite - one surface, anterior (D2330). You say that 
you do not believe the correct amount was covered for the service you received. The Plan denied your request. 
The Plan says the claim was processed correctly using the allowed amount for an out-of-network provider. 
 
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 rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for comprehensive dental in-network and out-of-network. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested resin-based composite - 
one surface, anterior is covered with a 50% coinsurance under this benefit. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to pay more for the resin-based composite - one surface, anterior (D2330) provided on July 18, 2023.
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 enrollee has on going medical needs 
that can be addressed and cared for at a LTACH. The Plan denied your request. The Plan says it is not safe for 
the enrollee to leave the hospital at this time because having had a fever in the past 24 hours based on the most 
recent available progress note. The Plan says the enrollee can stay in the hospital until it is safe for transfer or 
discharge. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient mental health services provided 
from January 4, 2022, to June 7, 2023. 
 
You asked the Plan to waive the coinsurance for the outpatient mental health services. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for outpatient mental health care out-of-network.  
 
You have been asked to pay a 50% coinsurance for the outpatient mental health services. This service falls 
within the outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for outpatient mental health services provided from January 4, 2022, to June 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 3, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on May 3, 2023.