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 you are currently in the hospital. You also say that 
you require inpatient rehabilitation that consists of a higher level of care where you can have therapy multiple 
times a day. The Plan denied your request. The Plan says you do 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 you are medically stable and do not need a physical medicine and rehabilitation 
physician's supervision 3 times a week in an IRF. There is no current medical complexity and no acute 
rehabilitation nursing needs documented. You do not need specialized 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 document 
does not support necessity for admission to an IRF. The complexity of your nursing, rehabilitation, and medical 
needs (combined complexity) do not require an acute hospital inpatient rehabilitation stay with an 
interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be provided in an alternate and 
low intensity setting such as 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the shoulder orthosis provided on September 
2, 2022. 
 
You asked the Plan to waive the cost share for the shoulder orthosis. You say that you did not want this device 
and have not used it. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is an $800 deductible which applies to in-network durable medical 
equipment and related supplies. Your contract with the Plan also clearly says you must pay 10% coinsurance 
for in-network durable medical equipment and related supplies. You have been asked to pay $56.70 towards the deductible. The item or service you asked the Plan to waive the 
cost share for falls within the durable medical equipment and related supplies benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is an $800 deductible which applies to 
in-network durable medical equipment and related supplies. This cost sharing is a contractual obligation that 
had not been met at the time the shoulder orthosis was received on September 2, 2022.  
 
You have also been asked to pay $6.30, which is 10% coinsurance of the allowed amount for the shoulder 
orthosis ($63 allowed amount x 10% coinsurance = $6.30). This item/service falls within the durable medical 
equipment and related supplies benefit category. You have been asked to pay a total of $63 for the shoulder 
orthosis ($56.70 deductible + $6.30 coinsurance = $63). 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 cost share for the 
shoulder orthosis provided on September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 25, 2023. 
 
You asked the Plan to pay for office visit. You say that you are requesting the submitted documentation be 
reviewed. 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 office visit provided on 
January 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips (A0120). 
 
You asked the Plan to pre-approve routine transportation trips. You say that you need transportation to your 
medical appointments. The Plan denied your request. The Plan says routine transportation trips are not covered 
by your benefit plan. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation trips have not been met. Routine transportation 
trips are not covered by your benefit plan. Therefore, we decided that the Plan does not have to pre-approve 
routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heavy-duty wheeled walker (E0149) provided on October 
8, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the heavy-duty walker. You say that this should be covered. The Plan denied 
your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the 
Plan does not have to pay for the heavy-duty wheeled walker (E0149) provided on October 8, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90792 for date of service November 14, 
2022. 
 
You asked the Plan to pay for procedure code 90792. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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. 
 
In this case, the CPT Code Manual definition of code 90792 is psychiatric diagnostic evaluation with medical 
services. 
 
We find that CPT code 90792 is not supported in the medical record. Specifically, this service was billed with 
primary diagnosis F06.34 (Mood disorder due to known physiological condition with mixed features). This 
diagnosis code has a code first note, meaning that an underlying condition should be sequenced first.  The claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 90792 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 90792 for date of service November 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are ill and need the intensive level of IRF 
services. You also say you would like to pursue an IRF admission to return to independent living. The Plan 
denied your request. The Plan says you do 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the brain. 
 
You asked the Plan to pre-approve an MRI of the brain. You say that you suffer from memory loss, dizziness, 
and severe head pain. The Plan denied your request. The Plan says an MRI of the brain is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the brain. Our reviewer says 
that an MRI of the brain if not medically necessary. Our physician reviewer found that there was no discussion 
of any other associated symptoms that would prompt a need for imaging of the brain. Also, there were no red 
flag findings noted in the records that would warrant an MRI of the brain for a headache disorder. Therefore, 
the request for the MRI of the brain is not reasonable or 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 an MRI of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the brain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal tooth #7, 
#8, #9 (D6240) and retainer crown - porcelain fused to high noble metal tooth #6 (D6750). 
 
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. Therefore, we decided that the Plan does 
not have to pre-approve pontic - porcelain fused to high noble metal tooth #7, #8, #9 (D6240) and retainer 
crown - porcelain fused to high noble metal tooth #6 (D6750).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the daratumumab injection provided on November 2, 2022.  
 
You asked the Plan to pay for the daratumumab injection. You say that prior authorization was provided for the 
injection. The Plan denied your request. The Plan says the services were not approved in advanced. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that authorization rules may apply for in-network and out-of-network for Medicare Part B 
prescription drugs. 
 
  The Plan requires prior authorization for the items/services at issue in this appeal. The Plan did not pre-approve 
the item/service at issue for no prior authorization. We found no exception that would require the Plan to pay 
for these items/services. Therefore, we decided that the Plan does not have to pay for the daratumumab 
injection provided on November 2, 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 you are requesting reconsideration for 
the denial of an LTACH admission based on medical necessity. The Plan denied your request. The Plan says 
the Medicare criteria for medical necessity has 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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The Plan has approved ongoing care in the current acute care 
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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve fixed partial denture sectioning. 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 pre-approve fixed 
partial denture sectioning (D9120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MedaCube device (S5185) provided on January 12, 2023. 
 
You asked the Plan to pay for the MedaCube. You say that you are on about ten prescriptions. You say that it is 
difficult for you to open the bottles. You say that you forget to take your required medications. You also say 
that the MedaCube is able to select your dosage and remind you to take your medications. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the MedaCube have not been met. The 
record does not contain a valid physician order or relevant medical records which support medical necessity for 
the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the MedaCube 
device (S5185) provided on January 12, 2023.
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 is still in the hospital and is medically 
stable to be transferred to an acute IRF. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at a lower level of care.  
 
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 enrollee does 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 pre-approve pontic - porcelain fused to high noble metal for tooth #7 
(D6240), retainer crown -porcelain fused to high noble metal for tooth #6 (D6750). 
 
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. Therefore, we decided that the Plan does 
not have to pre-approve pontic - porcelain fused to high noble metal for tooth #7 (D6240), retainer crown -
porcelain fused to high noble metal for tooth #6 (D6750).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96401 and G0463 for date of service August 
9, 2022. 
 
You asked the Plan to pay for procedure codes 96401 and G0463. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as 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 CPT codes 96401 and G0463 are not supported in the medical record. Specifically, these services 
were not reported with a clinical trial number. The claim is not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 96401 and G0463 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 96401 and G0463 for date of service August 
9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has a serious, life-threatening 
constellation of acute medical problems that have left them at a functional status below their baseline. You also 
say the enrollee requires close daily oversight of care by a physician in an inpatient setting. 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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. There is not 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. 
 
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 an IRF admission and services.