Persius/hicric huggingface dataset:
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 too weak for inpatient 
rehabilitation due to not being able to tolerate 3 hours of physical therapy and their clinical needs are too 
complex for skilled nursing facility. You say that the enrollee will need complex trained clinical staff and an 
interdisciplinary treatment team driven to aggressive restoration. The Plan denied your request. The Plan says 
an LTACH admission 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 that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided by the 
Health Plan. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device 
 
You asked the Plan to pre-approve a continuous passive motion device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the notes show surgery was completed on August 23, 
2023 and there is insufficient evidence to justify coverage for this device 
 
The Plan must follow Medicare rules. Medicare rules say that a continuous passive motion device is medically 
necessary if member has had total knee replacement and needs the device within 2 days following surgery.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a continuous passive motion device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous passive motion device
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin based composite three surfaces, posterior for tooth 
#32 (D2393), porcelain/ceramic crown for tooth # 14 (D2740) and a core buildup (D2950). 
 
You asked the Plan to pre-approve resin-based composite, a porcelain/ceramic crown, and a core buildup. You 
say that this is medically necessary. The Plan denied your request. The Plan says the services to tooth # 14 
were denied as there was no evidence of a defective crown or recurrent caries. For tooth # 32 the requested 
services were denied as there wasn't radiographic evidence of caries or a defective restoration. 
 
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 resin-based 
composite, a porcelain/ceramic crown and a core buildup 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 resin-based composite, a 
porcelain/ceramic crown and a core buildup. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found included was a full mouth series of x-rays. Tooth #32 has an existing large composite 
filling. Tooth #14 has an existing porcelain fused to metal crown or a porcelain fused to zirconia crown. There 
is no apparent decay noted on the x-rays. The clinical notes also do not document any conditions related to 
teeth #14 and 32. Based on the information provided, D2393 (resin-based composite, three surfaces, posterior) 
for tooth #32, and D2740 (crown-porcelain/ceramic) and D2950 (core buildup, including pins when required) 
for tooth #14 is not medically reasonable or necessary. More information is needed to support medical 
necessity of the requested procedures. 
 
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 resin-based composite, a porcelain/ceramic crown and a core buildup have not 
been met. Therefore, we decided that the Plan does not have to pre-approve resin based composite three 
surfaces, posterior for tooth #32 (D2393), porcelain/ceramic crown for tooth # 14 (D2740) and a core buildup 
(D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal emergency response system. 
 
You asked the Plan to pre-approve personal emergency response system. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a personal emergency response system is not 
covered by Original Medicare but may be offered by a Medicare Advantage plan as a supplemental benefit. 
Your contract with the Plan says that a personal emergency response system is not offered as a supplemental 
benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal emergency response system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a personal emergency response system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you tried to resubmit the claim 
through the Plan, but it was voided due to it initially being denied. The Plan denied your request. The Plan says 
the genicular nerve block 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 the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is considered experimental for knee pain. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
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 needs this care to return to 
prior level of function.  The Plan denied your request. The Plan says the enrollees medical condition does not 
require LTACH services, and care can be provided in another 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 medical records do not support that the enrollee requires 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 pay for the transport chair purchased on August 23, 2023. 
 
You asked the Plan to pay for the transport chair. You say that the item was medically necessary. The Plan 
denied your request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the transport chair purchased on August 
23, 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 an LTACH is the most appropriate 
setting for the enrollee to continue to receive their ongoing care. The Plan denied your request. The Plan says 
criteria for admission to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the 
acute care hospital. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service June 21, 
2023, to June 27, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says an incorrect bill type was submitted on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim at issue was submitted with TOB 323, which is not a payable 
TOB code for the services provided. 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 the home 
health care billed for dates of service June 21, 2023, to June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99379 billed for date of service July 11, 
2023. 
 
You asked the Plan to pay for procedure code 99379. You say that the physician provided medically necessary 
services. The Plan denied your request. The Plan says procedure code 99379 is considered bundled and not 
separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99379 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99379 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99379 billed for date of service July 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart catheterization and ventriculography (93458). 
 
You asked the Plan to pre-approve heart catheterization and ventriculography. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary as the enrollee does not 
have an acute coronary syndrome. There is no high-risk finding on non-invasive test. There is no anti-anginal 
therapy prescribed. 
 
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 heart catheterization and 
ventriculography. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has suspected stable coronary artery 
disease, with a moderate-risk stress test. The enrollee has not been treated with anti-anginal therapy. As such, 
the medical records provided do not support the rationale for this invasive imaging study. Guidelines do not 
support a need for cardiac catheterization in this 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 heart catheterization and ventriculography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve heart catheterization and ventriculography (93458).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace (L1851, L2397) provided on April 18, 2023. 
 
You asked the Plan to pay for the knee brace. You say that the items should be covered. The Plan denied your 
request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication the items were needed, discussed or ordered in the clinical records submitted. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the knee brace (L1851, L2397) 
provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin grafts. 
 
You asked the Plan to pre-approve skin grafts. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental/investigational. 
 
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 skin grafts. 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 proof in medical literature recommending skin substitute therapy for the treatment of 
pressure ulcers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin grafts have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skin grafts.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on 
September 1, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were able to drive 
yourself to the emergency room. The Plan denied your request. The Plan says the Medicare ambulance benefit 
is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 1, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on September 1, 2023.
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 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 the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees 
medical problems are stable. While the medical record supports a need for physical 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.  
 
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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says these services can be provided safely in an alternate 
setting.  
 
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 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. The enrollee requires treatment by multiple therapies. There is documentation that there 
is 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, but the services required can be provided at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutment tooth 22 (D6056) and abutment 
supported porcelain/ceramic crown tooth 22 (D6058). 
 
You asked the Plan to pre-approve prefabricated abutment and abutment supported porcelain/ceramic crown. 
You say that this is medically necessary. The Plan denied your request. The Plan says this request is not 
medically necessary. This can be covered if x-rays sent by your provider show existing implants have fused 
well with the bone. The records sent do now show the implant has fused well with the bone. 
 
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 prefabricated 
abutment and abutment supported porcelain/ceramic 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 prefabricated abutment and abutment 
supported porcelain/ceramic crown. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found included was a panoramic x-ray dated 2/6/2023 which shows tooth #22 missing 
clinically. There were no clinical records documenting an implant in tooth #22 area, nor were here any x-rays 
or photos included that show an implant. Based on the information provided, D6056 (prefabricated abutment-
includes modification and placement), D6058 (abutment supported porcelain/ceramic crown), and D6104 (bone 
graft at time of implant placement) for tooth #22 is not medically reasonable or necessary. D0383 is not also 
medically reasonable as this x-ray captures both jaws. A limited area around tooth #22 would be more 
medically reasonable. 
 
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 prefabricated abutment and abutment supported porcelain/ceramic crown have 
not been met. Therefore, we decided that the Plan does not have to pre-approve prefabricated abutment tooth 
22 (D6056) and abutment supported porcelain/ceramic crown tooth 22 (D6058).