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 require the 24-hour care available at an IRF. The 
Plan denied your request. The Plan says your needs can be met in a skilled nursing facility (SNF).  
 
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 can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30-minute interval (G0277) and physician attendance and supervision of hyperbaric oxygen therapy, per 
session (99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy (HBOT). You say that the enrollee has necrosis 
and gangrene, and therapy will improve wound healing, so no further surgery or amputation is required. The 
Plan denied your request. The Plan says the records show that the enrollee had a recent surgery and has a non-
healing surgical wound. HBOT is not the primary treatment for this type of wound. 
 
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 hyperbaric oxygen therapy (HBOT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the medical records provided there is no documentation that 
the hyperbaric oxygen therapy at issue in this case meets all Medicare criteria for medical necessity and/or is 
safe and effective for the enrollee. Provided records in this case do not document a covered diagnosis for the 
treatment per NCD 20.29. Foot wounds related to a prior surgical reconstruction procedure is not a covered 
indication for the service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy (HBOT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute 
interval (G0277) and physician attendance and supervision of hyperbaric oxygen therapy, per session (99183).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt, legrests, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that this 
is medically necessary for the enrollee. The Plan denied your request. The Plan says the notes do not show a 
medical need for the requested multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain 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 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found a multiple power option base is covered if the 
enrollee meets coverage criteria for a power tilt and recline seating system and the system is being used on the 
wheelchair or if the enrollee uses a ventilator which is mounted on the wheelchair. The provided records do not 
document this enrollee will be using power tilt and recline or a ventilator. The reviewer found that only power 
tilt is requested with this wheelchair, thus the multiple power option base does not meet coverage criteria. As 
the requested wheelchair base does not meet Medicare coverage criteria, the requested accessories are not 
covered. 
 
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 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt, legrests, seat elevator) and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crowns (D2740 x2) provided on 
October 16, 2023. 
 
You asked the Plan to pay for the porcelain/ceramic crowns (D2740 x2). You say that there was decay under 
your existing crowns. You say your policy should at least cover the cost of fixing the tooth decay and it needed 
to be fixed. The Plan denied your request. The Plan says the services are not covered 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 porcelain/ceramic crowns (D2740 
x2) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the porcelain/ceramic crowns (D2740 x2) provided on October 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care services provided on August 
18, 2023, by an out-of-network (OON) provider.  
 
 
 You asked the Plan to pay for the subsequent nursing facility care services. You say that the claim should be 
reprocessed for payment as the services provided were medically necessary. The Plan denied your request. The 
Plan says there was no prior authorization requested and the services provided were not an emergency or 
urgently needed. 
 
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 subsequent nursing facility care services provided 
on August 18, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radical nephrectomy to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the radical nephrectomy. You say that the right mass concerning for 
malignancy and possible metastasis if further delayed. The Plan denied your request. The Plan says in-network 
providers are available. 
 
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 radical nephrectomy to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this procedure would benefit the 
enrollee. The Plan denied your request. The Plan says this procedure is considered experimental. 
 
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 Intracept procedure. 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 stenosis. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided on July 18, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a continuous glucose monitor (CGM). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
prior authorization is required for an out-of-network visit. 
 
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 a continuous glucose monitor (CGM) provided on 
July 18, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on July 4, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on July 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483). 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation system. 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 high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet specific criteria. 
 
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 high frequency chest wall oscillation 
system. Our reviewer says that the services are not medically necessary. Our physician reviewer found a high-
frequency chest wall oscillation device is not medically necessary. There is inadequate evidence that the chest 
wall oscillation device would be effective in this setting, and Medicare requirements are not met. 
 
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 high frequency chest wall oscillation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (code J3490) provided on October 9, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this was a medically necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says this is included in the global surgical package for 
surgery procedure 27096. 
 
The Plan must follow Medicare rules. Medicare rules say that intra-operative services that are normally a usual 
and necessary part of a surgical procedure are included in the global surgical package when performed by the 
same physician.  
 
We looked at the file and Medicare rules. This local anesthetic bupivacaine is a usual and necessary intra-
operative service so is not separately payable from the surgical procedure 27096. Based on this information, we 
decided that Medicare rules for coverage of bupivacaine have not been met. Therefore, we decided that the 
Plan does not have to pay for bupivacaine (code J3490) provided on October 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexlizet. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary. 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 Nexlizet.  Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on August 04, 2023. 
 
You asked the Plan to pay for a facility visit. You say that the physician depends on the hospital staff to obtain 
proper authorization. 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 a facility visit provided 
on August 04, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the office visits provided at an observation level of care from August 
15, 2023, to August 16, 2023, by the out-of-network provider. 
 
You asked the Plan to pay for the hospital care. You say that this is an illegal denial. You say that the enrollee 
was hospitalized. You also say that this should be paid. The Plan denied your request. The Plan says that the 
services performed does not match what was approved on the authorization. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 care. Our reviewer says that the 
hospital care provided from August 15, 2023, to August 16, 2023, was medically necessary. Our physician 
reviewer found he review indicates that the enrollee was evaluated in the emergency department and underwent 
laboratory studies and magnetic resonance imaging (MRI) of the brain. The records indicate that the enrollee was evaluated by Neurology and started on Keppra. The enrollee was also evaluated by Psychiatry. The 
enrollee had another seizure after a dose of Keppra. The enrollee was not stable for transfer to a Plan facility. 
The review has determined that for dates of service where there is no specific documentation by the treating 
physician regarding stability for transfer, based on the clinical documentation available in the medical record 
the enrollee was not stable for transfer on the dates of service in this case. The enrollee required services at the 
out-of-network facility. Therefore, the reviewer found that the hospital care was medically necessary and 
reasonable. 
 
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 care have been met. Therefore, we decided that the Plan has to pay 
for the office visits provided at an observation level of care from August 15, 2023, to August 16, 2023, by the 
out-of-network provider.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 22, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 office visit provided on August 22, 2023, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain fused crown (D6750) for teeth #22 and #26, 
and pontics (D6240) for teeth #23, #24, and #25 
 
You asked the Plan to pre-approve D6750 and D6240. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says the requested dental services are not medically necessary. 
 
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 D6750 and 
D6240 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 D6750 and D6240. Our reviewer says 
that this dental work is not medically necessary. Our physician reviewer found these teeth have severe bone 
loss, and a dental bridge is not recommended. The teeth that will anchor the dental bridge (#22,26) have a poor 
prognosis, and a dental bridge is not recommended as it will fail. Teeth with severe bone loss tend to be mobile. A dental bridge is placed on teeth that have a strong periodontal foundation (has a lot of bone and gums 
surrounding the teeth). These teeth do not have the structural support system to support the dental bridge.  
 
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 D6750 and D6240 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a porcelain fused crown (D6750) for teeth #22 and #26, and pontics (D6240) for teeth 
#23, #24, and #25