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 you are formally requesting a fast appeal as you have 
a facility who has clinically accepted you. You say you are attaching evidence that supports that you do need 
inpatient rehabilitation which was not available during the initial review. The Plan denied your request. The 
Plan says the request 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 the complexity of your nursing, medical and rehabilitation needs do 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. 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs that level of care. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they currently receiving care. 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.  
 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 power wheelchair and accessories (K0861, E0955, 
E0956, E1007, E1012, E1028, E2313, E2361, E2377, E2607, E2620, K0108). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare 
guidance says that a special power wheelchair is medically necessary for enrollees that require both power tilt 
and power recline. The notes do not show that the enrollee needs both of these power options. 
 
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 power wheelchair and accessories. 
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 need for a ventilator or for power tilt and recline. The documentation does not support that the enrollee is at high risk for development of a pressure ulcer, 
utilizes intermittent catheterization for bladder management, or needs a power seating system to manage 
increased tone or spasticity. The enrollee has no history of prior pressure ulcer and no documentation of flap 
surgery. There is documentation on October 4, 2023, that a walker will improve the enrollee's participation in 
chores and MRADLs. The request for power and tilt exceeds the enrollee's medical needs. As the group 3 
power wheelchair with multiple power options is not reasonable and necessary, none of the requested 
accessories can be covered. The base wheelchair was not approved therefore the accessories are not medically 
necessary. Also, the documentation also does not support that the enrollee does not have the functional ability 
and strength in the upper extremities to control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E0955, E0956, E1007, 
E1012, E1028, E2313, E2361, E2377, E2607, E2620, K0108).
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 would benefit from an acute inpatient 
comprehensive rehabilitation program to address their functional impairments including transfers, ambulation 
and activities of daily living. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines for services in an inpatient rehabilitation facility.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although the 
enrollee needs physical and occupational therapy and could tolerate the therapy in the IRF, the complexity of 
their condition doesnt require an IRF stay and care can be provided in a lower level.  
 
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 more for the complete denture - maxillary (D5110), complete 
denture - mandibular D5120), cone beam CT capture and interpretation with field of view of both jaws; with or 
without cranium (D0367) and unspecified procedure (D9999) provided on July 18, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you do not agree with your responsibility. 
The Plan denied your request. The Plan says your benefit for the requested services $1,000 dollar limit was 
met. 
 
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 cone beam CT capture and 
interpretation with field of view of both jaws; with or without cranium (D0367) and unspecified procedure 
(D9999) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay more for the cone beam CT capture and interpretation with field of view of both jaws; with or without 
cranium (D0367) and unspecified procedure (D9999) provided on July 18, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services $1,000 dollar limit was exhausted on date of service July 18, 
2023. The dentures applied a 20% coinsurance and you reached your annual benefit limit with those services. 
Therefore, we decided that the Plan does not have to pay more for the complete denture - maxillary (D5110), 
complete denture - mandibular D5120) provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on June 9, 2023. 
 
You asked the Plan to pay for acupuncture services. You say that you have developed shingles in September of 
2022 and continue to have issues with the pain. You say that you were told that the acupuncturist advised you 
they only treat back pain. The Plan denied your request. The Plan says that acupuncture is only covered for 
chronic low back pain. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have pain around your ear and down your neck, 
and acupuncture is only covered for chronic low back pain. Therefore, we decided that the Plan does not have 
to pay for acupuncture services provided on June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, with a forced 
expiratory volume (FEV1) of 49% of predicted in July 2019. The enrollee has had 3 hospital admissions over 
the past year for COPD exacerbations. Arterial blood gases (ABGs) on most recent admission showed acute on 
chronic hypercarbic respiratory failure. There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease.  This enrollee may benefit from BiPAP with average volume-assured pressure support (AVAPS) 
during sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the photochemotherapy provided on July 5, 
2023. 
 
You asked the Plan to reduce the cost share for the photochemotherapy. You say that you should only have a 
$45 copayment. 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 a $1,000 deductible which applies to physician/practitioner services, 
including doctors office visits. Your contract with the Plan also clearly says that you must pay $65 copayment 
for services from a specialist. 
 
You have been asked to pay $131.27, which satisfied the deductible for the photochemotherapy. The item or 
service you asked the Plan to reduce the cost share for falls within the physician/practitioner services, including 
doctors office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $1,000 deductible which applies to physician/practitioner services, including doctors 
office visits. This cost sharing is a contractual obligation that had not been met at the time the 
photochemotherapy was received on July 5, 2023.  
 
You have also been asked to pay $0.53, which is less than the standard copayment for the photochemotherapy. 
This item/service falls within the physician/practitioner services, including doctors office visits benefit 
category. 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 reduce the cost share for the photochemotherapy provided on July 5, 
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 you are requesting reconsideration for 
the denial of an LTACH admission. 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 where they are currently receiving care. 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. 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 core buildups (D2950) for tooth numbers 7, 8, 9, and 
10. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat properly, and crowns are 
needed because your teeth have been repeatedly chipped and broken. The Plan denied your request. The Plan 
says the criteria for coverage have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental 
services 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 the dental services. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that there appears to be sufficient 
coronal structure to provide adequate support and retention for crown restorations for teeth numbers 7, 8, 9 and 
10. Core buildups (D2950) do not meet the criteria for coverage for teeth numbers 7, 8, 9 and 10. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve core buildups (D2950) for tooth numbers 7, 8, 9, and 10.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the hospital observation services (G0378) provided from September 20, 
2021, to September 22, 2021. 
 
You asked the Plan to pay for the hospital observation services. You say that you would like these services to 
be authorized and approved for payment. The Plan denied your request. The Plan says that payment for this 
service has been denied because it was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the hospital observation services. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the services were medically necessary as the patient had a recommended 
disposition to subacute rehabilitation, as home discharge was not deemed to be safe. 
 
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 hospital observation services have been met. Therefore, we decided that the 
Plan has to pay for the hospital observation services (G0378) provided from September 20, 2021, to September 
22, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computer-assisted surgical navigational procedure 
for musculoskeletal procedures, image-less (20985). 
 
You asked the Plan to pre-approve the computer-assisted surgical navigational procedure. You say that you do 
not agree with this denial. The Plan denied your request. The Plan says this is experimental and therefore is not 
covered. 
 
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 computer-assisted surgical navigational procedure. Our reviewer says that the requested computer-assisted surgical navigational procedure 
is not considered medically reasonable and necessary in this case. Our physician reviewer found current 
literature does not sufficiently support this method for performing this surgery at this time. Therefore, the 
reviewer found that the requested computer-assisted surgical navigational procedure 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 computer-assisted surgical navigational procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the computer-assisted surgical navigational 
procedure for musculoskeletal procedures, image-less (20985).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from September 
22, 2023 onward. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the continued services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that 
the continued services are not medically necessary. Our physician reviewer found the enrollee was admitted to 
the hospital on August 30, 2023 with unspecified psychotic disorder to rule out schizoaffective disorder, 
bipolar type, and to rule out undifferentiated schizophrenia, unspecified impulse control disorder, and 
excoriation disorder. She was complaint with treatment and not showing any acute threats to her safety. It is not 
medically necessary to have inpatient psychiatric care beyond the dates in question, as she is not showing 
dangerousness to self or others. It does not appear that active treatment was taking place beyond the dates in 
question or that  continued services are reasonably expected to improve the enrollee's condition or for the 
purpose of diagnosis. The records do not support that continued inpatient psychiatric services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric services from September 22, 2023 onward.