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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from acute rehabilitation to 
optimize the level of functioning prior to returning home. The Plan denied your request. The Plan says an IRF 
admission is not reasonable and 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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build-ups (D2950) provided on February 15, 2022. 
 
You asked the Plan to pay for D2950. You say that these services should be covered. The Plan denied your 
request. The Plan says prior authorization was not obtained. 
 
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 D2950 when 
prior authorization has been obtained.  
 
We looked at the file and Medicare rules. Prior authorization was not obtained for D2950. Based on this 
information, we decided that the Plan's rules for coverage of D2950 have not been met. Therefore, we decided 
that the Plan does not have to pay for core build-ups (D2950) provided on February 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent pen. 
 
You asked the Plan to pre-approve Dupixent. You say that you disagree with the plan's denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent pen.  Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 continuation of SNF services is necessary because 
the enrollee is not able to get out of bed or into a wheelchair independently, has other medical issues, and has 
no one at home to help them. The Plan denied your request. The Plan says the enrollee appears to have 
optimized their progress through skilled therapy services and was no longer obtaining consistent, meaningful 
functional benefit from daily skilled therapies.  
 
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 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 and/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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on November 7, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee received three ambulance 
transporation visits on November 7, 2022. A Fourth visit is not supported. There is no evidence presented to 
support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the ambulance services provided on November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the provider is 
out-of-network, and it was determined these services can be received in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a continuous glucose monitor (CGM) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the enrollee has been diagnosed with essential tremor 
and a dystonic head tremor from cervical dystonia. You say that you feel treatment with Botox is medically 
necessary. You also say that this treatment would improve the enrollee's anxiety and balance. The Plan denied 
your request. The Plan says Botox is considered investigational for the treatment of essential tremor. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Botox. Our reviewer says that the 
request for Botox is not medically necessary. Our physician reviewer found the records provided for review 
indicated that the enrollee had essential tremor, possibly secondary to a dystonic component. However, the 
documentation provided did not support that the enrollee meets current diagnostic standards/criteria for cervical 
dystonia. The reviewer found that Botox is not otherwise medically reasonable and necessary for the 
management of essential tremor given a lack of credible references of efficacy. In as much it can also not be 
concluded that Botox would be safe and effective for the enrollee. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vanity flap (K0108). 
 
You asked the Plan to pre-approve the vanity flap. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the vanity flap (K0108).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on November 4, 2022. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the claim contains billing/coding errors. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the information in the file is insufficient to justify the Plans denial 
of payment. Therefore, we decided that the Plan has to pay for practitioner services provided on November 4, 
2022.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on June 29, 2022. 
 
You asked the Plan to pay for the physical therapy services. You say that this medical claim for physical 
therapy was a referral from a dentist for the diagnosis of TMJ. You say that you called and spoke to a 
representative who said that the enrollee's contract allowed for coverage. You say that the services provided 
were medically necessary and are supported by the documentation provided. The Plan denied your request. The 
Plan says the enrollee's contract does not cover charges for treatment of TMJ other than by an open-cutting 
operation.  
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary. Medicare rules also say that the patient's medical record should include certain elements in order to 
support medical necessity.  
 
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 pay for the physical therapy services. Our reviewer 
says that the criteria for coverage have not been met.  Our physician reviewer found the documentation 
available for review did not include a description of previous treatment such as patient education, the use of 
medications, or the use of bite splints.  There was not a relevant medical history or pertinent tests/procedures 
from the referring medical provider. There is no indication the enrollee failed initial conservative treatment that 
would require referral for skilled outpatient rehabilitation.  Additionally, the enrollee had previously been 
treated with outpatient therapies (starting in April 2022) and should have received adequate education and 
treatment to allow for home care. The requested therapy services were not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore were 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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services provided on June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospitalization provided from November 
27, 2021, to November 28, 2021.  
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee's treating physician 
determined that they required inpatient evaluation and treatment to rule out a cerebrovascular accident. You 
state that the Plan cannot recoup payments made to the treating facility because the Plan bears the burden of any payment made in error.  The Plan denied your request. The Plan says  the provided information does not 
support that criterion were met for inpatient hospitalization.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found due to low likelihood of cerebrovascular accident (CVA) and stability of the enrollee 
it was not expected that the enrollee would require hospital care that would have likely crossed 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospitalization provided from November 27, 2021, to 
November 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient care beginning August 1, 2023. 
 
You asked the Plan to pre-approve continuation of inpatient care beginning August 1, 2023. You say that 
continuation of inpatient care is medically necessary. The Plan denied your request. The Plan says the member 
is not receiving active treatment or the treatment being provided is not expected to be of clinical benefit. The 
member appears to be receiving custodial care. Custodial care is not a Medicare covered benefit. 
 
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 continuation of inpatient care beginning 
August 1, 2023. Our reviewer says that the requested continuation of inpatient care is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of hypertension 
dementia, depression, and multiple suicide attempts who was admitted on July 17, 2023. The enrollee was fully evaluated and has been receiving treatment. The review indicates that as of August 1, 2023 the enrollee was 
medically stable and was not receiving any inpatient diagnostic studies or therapeutic interventions. The 
enrollee's needs as of August 1, 2023 were custodial in nature. The review has determined that the continuation 
of inpatient care beginning August 1, 2023 was not medically reasonable or 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 continuation of inpatient care beginning August 1, 2023 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient care beginning 
August 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology service provided on March 9, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the pathology service. You say that prior authorization should be the referring 
provider's responsibility. You also say that this should be reprocessed and paid. 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 requested 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/service at issue. 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 pathology service provided on March 9, 2023, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan, head or brain; without 
contrast material (70450-26) provided on January 9, 2023. 
 
You asked the Plan to pay for the CT scan. You say that you are requesting reconsideration for services 
advising the coding department has reviewed the services and determined that the claim is coded correctly. The 
Plan denied your request. The Plan says the diagnosis codes associated to it, I67.82 (Cerebral ischemia) and 
S06.5X0A (Traumatic subdural hemorrhage without loss of consciousness, initial encounter), should not be 
reported together which is based on the Excludes1 Notes instructions. 
 
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 coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the CT scan. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. The provider reported ICD-10 I67.82-Cerebral ischemia 
which per ICD 10 guidelines has an "Excludes1" with S06.5.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the computed tomography (CT) scan, head or brain; without contrast material (70450-26) 
provided on January 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve. 
 
You asked the Plan to pre-approve a surgery. You say that the enrollee has back pain that has greatly impacted 
their quality of life. The Plan denied your request. The Plan says there is not enough research to approve this 
procedure. 
 
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 a surgery. 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 magnetic resonance imaging (MRI) showing only modic changes without facet joint 
disease or foraminal stenosis. The cause of back pain is also not clear. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a thermal destruction of intraosseous basivertebral nerve.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary to see if the 
enrollee has Alzheimer's disease. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the magnetic resonance imaging (MRI) 
was said to have been most suggestive of a vascular dementia. There was no mention of a suspicion of FTD in 
the records. The requested study would not meet the base requirement of the NCD for coverage at this time. 
For these reasons the service would not be reasonable and 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.