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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria and to achieve a safe and sustainable discharge, admission to the LTACH is the best option. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for admission to an LTACH.  
 
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 that all medically necessary care is being provided in the current acute care setting. 
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. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial.  
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the medical records provided 
support the need for the requested services.  The Plan denied your request. The Plan says the request is not 
medically necessary because the records show that the enrollee has not been evaluated by a spine surgeon 
indicating that they are not a surgical candidate. The Plan says that the enrollee also has not received physical 
therapy.  
 
The Plan follows Medicare rules. Medicare rules say that the implantation of dorsal column or depth brain 
stimulators are only covered if the implantation of the stimulator is used as a late resort and when other 
treatment modalities have been tried.  
 
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 spinal cord stimulator trial. Our 
reviewer says that the criteria for coverage have not been met.  Our physician reviewer found the records do 
not show that all available treatment options have been tried. There is no documentation of a surgical 
consultation for spine surgery. 
 
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 spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management service (code 99397) billed for date of 
service December 15, 2022. 
 
You asked the Plan to pay for the billed services. You say that your annual wellness exam has always been 
covered in the past.  The Plan denied your request. The Plan says that the services are not covered.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
In this case, the services at issue were provided by a contract provider. The file does not show that the Plan 
provided notice that the billed services would not be covered. Under Medicare rules, this means the billed 
services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the evaluation 
and management service (code 99397) billed for date of service December 15, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve therapeutic parenteral drugs. 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 
therapeutic parenteral drugs (D9612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99336) provided on December 06, 
2022. 
 
You asked the Plan to pay for the domiciliary visit (99336). You say that the service was medically necessary. 
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 the domiciliary visit 
(99336) provided on December 06, 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 would like reconsideration based on the records 
submitted.  The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services 
requested do not meet the requirements for approval.  
 
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 documentation does not support the necessity for admission to an IRF. The 
complexity of the enrollee's nursing, rehabilitation, and medical needs does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the enrollee may 
benefit from physical therapy and/or occupational therapy, the enrollee's rehabilitation needs can be provided in 
a lower intensity and alternate setting once their pain is controlled to participate in therapies.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that the therapeutic CGM is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a therapeutic CGM. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has 
problematic hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
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 therapeutic CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic CGM.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prescription eyewear provided on September 28, 2022. 
 
You asked the Plan to pay for the prescription eyewear. You say that the retailer is a network provider. and you 
could not obtain authorization.  The Plan denied your request. The Plan says the provider was out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the prescription eyewear have not been met. 
Therefore, we decided that the Plan does not have to pay for the prescription eyewear provided on September 
28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the records provided support the need 
for the requested procedure.  The Plan denied your request. The Plan says the records provided support the 
need for the requested 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 CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
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 would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebroplasty. 
 
You asked the Plan to pre-approve percutaneous vertebroplasty. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 percutaneous vertebroplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the magnetic 
resonance imaging (MRI) does not show an acute fracture less than 6 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous vertebroplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 19, 2022, to 
August 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N17.0, described as acute 
kidney failure with tubular necrosis. 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found the enrollee presented with right leg cellulitis.  There is no 
evidence of renal failure or tubular necrosis.  AS such, the billing of N17.0 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 19, 2022, to August 25, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 You asked the Plan to pre-approve the additional routine transportation trips. You say that you need the 
additional trips to cover 15 radiotherapies you have left. The Plan denied your request. The Plan says the 
evidence shows you have used thirty-two (32) one-way trips this year (2023). 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 32 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants for teeth #2, #3, and #19. 
 
You asked the Plan to pre-approve dental implants. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says not medically necessary, Dental implants are a benefit only when 
exceptional medical conditions are documented and reviewed for medical necessity. There is no indication in 
the dental records that the member has exceptional medical conditions. 
 
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 dental 
implants 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 dental implants. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation indicates that the plan 
may consider implant services only when exceptional medical conditions are documented that would 
contraindicate other methods of tooth replacement. There was no documentation expressing the need for dental 
implants to replace the missing teeth. 
 
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 dental implants have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental implants for teeth #2, #3, and #19.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left atrial appendage closure device (LAAC) (33340). 
 
You asked the Plan to pre-approve LAAC. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that LAAC is covered when specific criteria are met, such as if 
the enrollee is unable to take oral anticoagulants. 
 
   
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 LAAC. 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 apparent contraindication to anticoagulation. As such, guidelines would not support 
implantation of a LAAC in this 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 LAAC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve left atrial appendage closure device (LAAC) (33340).
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 requesting reconsideration. The Plan denied 
your request. The Plan says the IRF services you are requesting do not meet the requirements for approval.  
 
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 documentation does not support the necessity for admission to an IRF. The 
complexity of the enrollee's nursing, rehabilitation, and medical needs does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the enrollee may 
benefit from physical therapy and/or occupational therapy, the enrollee's rehabilitation needs can be provided in 
a lower intensity and alternate setting such as in an SNF.  
 
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.