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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says you do not have acutely complex medical diagnosis and does not require supervision by 
a rehabilitation physician. You do not require an intensive rehabilitation program to return to preadmission 
baseline. You do not meet all the required 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission is a medical necessity.  
The Plan denied your request. The Plan says the requested service 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 appears to  be currently unstable for transfer and requires additional 
acute care services that can safely be provided at the current facility until more stable. 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 the enrollee is not yet stable for transfer and as it would 
not be clinically advantageous. 
 
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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute 
rehabilitation to optimize their level functioning prior to returning home. 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 is medically stable and does not need a physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. There is no current medical complexity or  
acute rehabilitation nursing needs documented. The enrollee does not need specialized and intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. The complexity of the enrollee's nursing, rehabilitation, and medical, needs (combined complexity) does 
not require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. The 
enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such an in a 
skilled nursing facility. 
 
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 issue reimbursement for the unspecified preventive procedures, by 
report (D1999) provided on January 9, 2023 and February 16, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit.  
 
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 services provided are not among 
those covered under this benefit.   
 
 
Therefore, we decided that the Plan does not have to issue reimbursement for the unspecified preventive 
procedures, by report (D1999) provided on January 9, 2023 and February 16, 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 due to your medical complexity and 
infections, the LTACH is medically necessary. You say a lower level of care is not appropriate. The Plan 
denied your request. The Plan says the LTACH is not medically necessary, and your needs can be met at a 
lower level of care such as an inpatient rehabilitation facility or skilled nursing facility. 
 
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 you were admitted to the acute care hospital with respiratory failure complicated by 
pneumonia, pleural effusion, wound dehiscence, anemia, encephalopathy, acute kidney injury, and a pharyngocutaneous fistula requiring salivary stent placement, blood transfusion, and fluids. The record shows 
you are tolerating weaning, tube feeds, and responding to current treatment. You appear to be improving at this 
time and requires only short-term additional acute care services that can safely be provided at the current 
facility until more stable and appropriate for a lower level of care. You do not require services at the LTACH 
that are not already available at the current facility.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
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 the enrollee does not need this item. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. 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 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertical shock reducing pylon feature (L5988). 
 
You asked the Plan to pre-approve the vertical shock reducing pylon feature. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 vertical shock reducing pylon 
feature. Our reviewer says that the enrollee does not need this item. Our physician reviewer found the 
documentation does not support that the enrollee will be participating in high impact activities that require the 
requested item. 
 
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 vertical shock reducing pylon feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertical shock reducing pylon feature (L5988).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you have a lot of 
physical therapy appointments. You also say that these are not enough rides to keep up with your health. The 
Plan denied your request. The Plan says transportation benefits beyond the 100 allotted one-way trips are not 
covered under the Medicare Program or the Plan.  
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 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips. 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 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for dates of service December 
28, 2022, and January 4, 2023. You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says an appropriate 
diagnosis code was not billed. 
 
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 on both claims, CPT code 99232 was billed with primary diagnosis code F05. This diagnosis code 
has a code first notation. This code is not permitted to be used as a primary diagnosis code. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 99232 billed for dates of service December 
28, 2022, and January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trigger point injections provided on October 17, 2022. 
 
You asked the Plan to pay for trigger point injections. You say that medical records support the services. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for trigger point injections 
provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia-first 15 minutes 
(D9222), deep sedation/general anesthesiaeach subsequent 15 minute increment (D9223 x 7), alveoloplasty in 
conjunction with extractions-four or more teeth or tooth spaces, per quadrant (D7310 x 2), and a buccal/labial 
frenectomy (D7961). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
supplemental dental policy.  
 
  
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep 
sedation/general anesthesia-first 15 minutes (D9222), deep sedation/general anesthesiaeach subsequent 15 
minute increment (D9223 x 7), alveoloplasty in conjunction with extractions-four or more teeth or tooth spaces, 
per quadrant (D7310 x 2), and a buccal/labial frenectomy (D7961).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the appropriate level of care 
for the enrollee. You also say that this transfer is needed for the enrollee's complex medical needs. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information we have about the 
enrollee's condition they do not meet all the requirements.  
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services.  The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. The elements of coverage rules are not satisfied.  
 
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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5225) and mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 17, 2020. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture (D5225) and mandibular partial denture (D5226).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service December 
13, 2022. 
 
You asked the Plan to pay for the billed service. You say that the drug screen provides valuable information for 
the physician to use. The Plan denied your request. The Plan says the service did not meet the Medicare rules 
for approval. 
 
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, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not 
show that the testing of 22 or more drug classes was ordered due to medication side effects or inefficacy, 
suspicious behaviors, self-escalation of dose, indications/symptoms of illegal drug use, evidence of diversion, 
or other clinician documented change in affect or behavioral pattern. Based on this information, we decided 
that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code G0483 billed for date of service December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a POV is covered if the criteria listed in the Medicare 
Rules section is 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 a power scooter. Our reviewer says that 
you do not need this medical item. Our physician reviewer found you are able to walk 100 feet, which is more 
than a household distance. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens, premium - Tier 4 provided on 
November 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the progressive lens. You say that you have a plan with OON benefits so this 
visit should have been covered. The Plan denied your request. The Plan says this claim was from an OON 
provider. The Plan also says that your benefit Plan does not cover this OON vision care service/material. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are provided by a Plan-approved Vision Provider. 
 
 
 
 We looked at the file and the Plan's rules. Although your Plan offers coverage for services rendered OON, the 
contract clearly states that standard frames and lenses from a Plan-approved Vision Provider are covered in full 
after each Post Cataract surgery.  Based on this information, we decided that the Plan's rules for coverage of the 
progressive lens have not been met. Therefore, we decided that the Plan does not have to pay for the 
progressive lens, premium - Tier 4 provided on November 4, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 6, 2022, to 
January 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 6, 2022, to 
January 31, 2022.