Persius/hicric huggingface dataset:
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 the enrollee requires SNF services to address 
functional deficits. The Plan denied your request. The Plan says a SNF admission is not medically necessary.  
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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing 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 pay for custom fabricated abutment and abutment supported 
porcelain/ceramic crown (D6057, D6058) provided on April 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for custom 
fabricated abutment and abutment supported porcelain/ceramic crown (D6057, D6058) provided on April 4, 
2023.
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 the request is medically necessary 
for chronic bilateral knee significantly limiting the enrollee's quality of life. 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 the genicular 
nerve block is considered experimental therapy and is the subject of ongoing clinical trials. 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2751) provided on December 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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 19, 2022. 
Therefore, we decided that the Plan does not have to pay more for a crown (D2751) provided on December 19, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is most appropriate 
for the enrollee to achieve the best outcome due to complex medical needs. The Plan denied your request. The 
Plan says  the enrollee's records do not show the need for continued care and treatments that can only be given 
in a 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered 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 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 group 2 heavy-duty power wheelchair (K0825). 
 
You asked the Plan to pre-approve a group 2 heavy-duty power wheelchair. 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 follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria 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 a group 2 heavy-duty power 
wheelchair. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
 
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 group 2 heavy-duty power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 heavy-duty power wheelchair (K0825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion with an out-of-network (OON) 
cardiologist.  
 
You asked the Plan to pre-approve a second opinion with an OON cardiologist. You say that you have 
researched the requested OON provider and found them to be best qualified to treat your condition. You say 
that spending time researching the network providers will cause a delay in care which is not good for your 
health and is causing you stress.  The Plan denied your request. The Plan says there are network cardiologists 
who are qualified to provide you with a second opinion regarding your condition and treatment.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 second opinion with an OON 
cardiologist. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet the 
enrollee's medical needs through referral to in-network cardiologists. There is nothing unique about the 
enrollee's condition that would make it medically necessary to see the requested OON provider. The Plan has 
shown that they have in-network providers who meet the Standards of Care required for treatment of the 
enrollee's condition.  
 
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 second opinion with an OON cardiologist have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a second opinion with an out-of-network (OON) 
cardiologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an ILR. You say that you disagree with the denial and have submitted 
additional medical records for review. The Plan denied your request. The Plan says the device is considered 
medically reasonable and necessary when the enrollee has episodes of syncope that are thought to be cardiac-
related, but not happen often enough to be detected by a Holter monitor. 
 
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 an ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had no history of atrial fibrillation, nor were any significant cardiac arrhythmias 
noted on electrocardiogram (ECG) monitoring. A recent randomized clinical trial found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial 
fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
enrollees at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) (33285).
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. 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 you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as 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 pre-approve a hearing aid fitting (V5011), a dispensing fee (V5241), 
and a digital, binaural hearing aid (V5261). 
 
You asked the Plan to pre-approve hearing aid fitting (V5011), dispensing fee (V5241), and a digital, binaural 
hearing aid (V5261). You say that your hearing is going. You also say you have to keep putting your volume 
up and people are getting bothered. The Plan denied your request. The Plan says Medicare does not pay for 
hearing aids. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
 
  Though hearing aid fitting (V5011), dispensing fee (V5241), and a digital, binaural hearing aid (V5261) may 
be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. 
Therefore, we decided that the Plan does not have to pre-approve a hearing aid fitting (V5011), a dispensing 
fee (V5241), and a digital, binaural hearing aid (V5261).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 87801. We decided that the Plan does not have to pay for 87150, 
87481, 87641, 87653, and 87798.  
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801 rendered on 
February 23, 2023.. You say that this should be paid for. The Plan says that the records do not support the 
services billed. 
 
We decided that the Plan has to pay for 87801.  
 
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 asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for CPT 87801. Our reviewer says that the provided 
records document that Acinetobacter baumannii, Citrobacter freundii and Enterobacter aerogenes were tested 
and reported in this case under code 87801. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
87801.  
 
We also decided that the Plan does not have to pay for 87150, 87481, 87641, 87653, and 87798. 
 
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 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 for the rest of the codes. Our reviewer says that the 
provider reported the rest of the procedure codes with modifier XU - unusual non-overlapping service to 
bypass the edit. The laboratory report does not include information to support a separately reportable procedure 
code and modifier. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87150, 87481, 87641, 87653, and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for 87150, 87481, 87641, 87653, and 87798. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unlisted evaluation and management service (99499). 
 
You asked the Plan to pre-approve an unlisted evaluation and management service. You say that you need 
stigmatized lenses in order to see properly and move around. Standard lenses are inadequate. The Plan denied 
your request. The Plan says upgraded lenses after cataract surgery are not covered. 
 
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 contract also says covered eyeglasses after cataract surgery includes standard frames and 
lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, 
tinting, progressive lenses or anti-reflective coating). 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of an unlisted evaluation and management service have not been met. Specifically, the EOC confirms 
that you are covered for one standard frame and lens after cataract surgery. An upgraded lens is not covered by 
the Plan. Therefore, we decided that the Plan does not have to pre-approve an unlisted evaluation and 
management service (99499).
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 you need more rehab services. The Plan denied your 
request. The Plan says a SNF admission is not medically necessary.   
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 that 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 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: 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 you are alone, and no one is taking care of you. You 
say that your spouse is unable to care for you because of their age. 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 you are medically stable and do not need physician supervision 3 times a week 
or intensive therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the 
enrollee may benefit from physical and occupational therapy the enrollee's needs can be provided in an 
alternate setting such as 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 pay for surgical placement of implant body (D6010), bone graft at 
time of implant placement (D6104), custom fabricated abutment (D6057) and abutment supported 
porcelain/ceramic crown (D6058) provided on January 31, 2023, to April 25, 2023. 
 
You asked the Plan to pay for these dental services. 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 
placement of implant body (D6010), bone graft at time of implant placement (D6104), custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on January 31, 2023, to 
April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability, 
without backup rate feature, used with noninvasive interface (E0470). 
 
You asked the Plan to pre-approve a respiratory assist device. You say that the requested device is necessary 
for the enrollee. The Plan denied your request. The Plan says the requested device is denied. There is no clear 
medical notes showing that the current device has been in use more than five (5) years, and it is not noted that 
the device is damaged, lost, or stolen. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a continuous positive airway pressure (CPAP) device. A continuous 
positive airway pressure (CPAP) device serves the same purpose as a respiratory assist device. Therefore, we 
decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability, 
without backup rate feature, used with noninvasive interface (E0470).