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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 enrollee is medically stable and does not need physicians supervision 3 times a 
week in an IRF. At the current functional level, the enrollee does not need intensive therapies consisting of at 
least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach in an IRF. The 
complexity of the enrollees medical, rehabilitation, and nursing needs (combined complexity) does not require 
acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. The 
enrollees rehabilitation needs can be safely provided in a low intensity alternate 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on September 6, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the lab testing. You say that the specimen was shipped for testing. The Plan 
denied your request. The Plan says there is no authorization on file. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who were capable of providing the items/services at issue in this appeal. (Please note, items and services 
received in-network are still subject to any other Medicare coverage rules that apply.) The Plan did not pre-
approve the services at issue. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for the lab testing services provided on September 6, 
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 electric assist pedal bike provided on July 23, 2023. 
 
You asked the Plan to pay for the provided service. You say that the bike will help with mobility. The Plan 
denied your request. The Plan says the bike does not meet the requirements for approval. 
 
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 pay for the electric assist pedal bike provided on July 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Verzenio. 
 
You asked the Plan to pre-approve Verzenio. You say that the drug is medically necessary for treatment. 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 Verzenio.   
Benefits for Verzenio 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endosteal implants (D6010 x2) and the extractions 
(D7140 x5) provided on October 21, 2022 
 
You asked the Plan to pay for the endosteal implants (D6010 x2) and the extractions (D7140 x5). You say that 
you had teeth removed and a temporary cosmetic denture attached. You say you have a $1,500 annual benefit 
and that should go towards paying for these services. The Plan denied your request. The Plan says the endosteal 
implants (D6010 x2) are not covered benefits and the extractions (D7140 x5) are not covered because benefit 
limit has been reached. 
 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 endosteal implants are not among 
those covered under this benefit. The record shows you reached your $1,000 maximum benefit limit on 
October 21, 2022, which exhausted the benefit. Therefore, we decided that the Plan does not have to pay for the 
endosteal implants (D6010 x2) and the extractions (D7140 x5) provided on October 21, 2022
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home physical therapy (PT) (G0151). 
 You asked the Plan to pre-approve home PT. You say that the enrollee is unstable, and is not getting the care 
they need. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home PT. Our reviewer says that the 
services are not medically reasonable and necessary. Our physician reviewer found the enrollee does not have 
documented home health PT needs.  Our reviewer also found that the enrollee is ambulatory and living in a 
supervised environment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home PT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home physical therapy (PT) (G0151).
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 needs ventilator 
management, intravenous therapy, physical therapy, and occupational therapy. The Plan denied your request. 
The Plan says the records do not show that the enrollee's doctors expect that the enrollee will benefit and 
improve with LTACH care. 
 
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 appears to still be unstable and requires short-term additional acute care 
hospital services that can safely be provided at the current facility until more appropriate for transfer. The enrollee does not require LTACH services that are not already available at the current facility. There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH is not medically necessary as the enrollee is a not stable for transfer and as it 
would not be clinically advantageous. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty and excision of torus mandibularis 
provided on April 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that the claim should not have been denied and ask 
that the claim be reprocessed. The Plan denied your request. The Plan says the enrollee's benefit for the 
requested item or service has already been exhausted. Also, the services requested are purely dental in nature. 
They are unrelated to the limited clinical indications. The services are not eligible for coverage under the 
medical benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollee has exhausted the 2023 benefit of the allowable $2,250 a year. Therefore, we decided that 
the Plan does not have to pay for the alveoloplasty and excision of torus mandibularis provided on April 4, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitoring supplies billed for date of 
service August 26, 2023. 
 
You asked the Plan to pay for the billed supplies. You say that relevant documentation was provided. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  The record does not contain a valid and complete physician order or relevant medical records which support 
medical necessity for the supplies provided in this case. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the continuous glucose monitoring supplies billed for date of service August 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and 
crown - porcelain/ceramic substrate (D0140, D2740) provided on July 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the crown was exhausted on date of service September 17, 2019, and the limited oral 
evaluation on May 10, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and crown - porcelain/ceramic substrate (D0140, D2740) provided on 
July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic office visit provided on August 23, 2023. 
 
You asked the Plan to pay for the chiropractic office visit. You say that the provider is in-network and this is a 
covered benefit. The Plan denied your request. The Plan says only manual manipulation of the spine to correct 
subluxation is covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic office visit provided on August 23, 2023.
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 is at a high risk for a poor 
outcome if they do not go to an LTACH facility as they require too much oxygen to go to a skilled nursing 
facility (SNF) or inpatient rehabilitation facility (IRF). The Plan denied your request. The Plan says the 
enrollee is receiving the care they need in the hospital where they are now and there is no need to transfer to the 
LTACH currently. 
 
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. 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 health plan. Given there are offered alternatives, LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says that admission to an IRF is not medically 
necessary and does not meet the criteria for coverage.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. There are no complex nursing or rehabilitation 
needs. 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 and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Ferumoxytol. 
 
You asked the Plan to pre-approve Ferumoxytol. You say that this drug is medically necessary for treatment. 
The Plan denied your request. The Plan says that this drug does not meet medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Ferumoxytol. Our reviewer says that 
requested drug is not reasonable and medically necessary. Our physician reviewer found the requested drug 
Ferumoxytol is FDA-approved for the enrollee's diagnosis. The enrollee has iron deficiency without anemia, 
with need for prior intravenous iron due to malabsorption in the past. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ferumoxytol have been met. Therefore, we decided that the Plan has to pre-
approve Ferumoxytol.  
 
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: 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 this is medically necessary. The Plan 
denied your request. The Plan says this 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 acute hospital can provide for all the patients present inpatient care needs and the 
patient is receiving an appropriate level of care in the present setting. The provided records do not explain what 
care services will be provided in the LTACH that are not available in the present hospital setting. Continued 
care in the short-term acute hospital is appropriate until the patient is stable to transfer to a lower level of care 
such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 an incomplete endodontic therapy (D3332) for tooth 
#14, and a cone beam CT capture (D0364). 
 
You asked the Plan to pre-approve D3332 and D0364. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says this dental work has been correctly denied. 
 
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 D3332 and 
D0364 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 D3332 and D0364. Our reviewer says 
that this dental work is not medically necessary. Our physician reviewer found the bone loss around the tooth is 
severe and the tooth has a guarded prognosis, root canal treatment may not be beneficial for the enrollee and other treatment options may be more beneficial for him. 
 
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 D3332 have not been met and D0364 is not a covered dental benefit. Therefore, 
we decided that the Plan does not have to pre-approve an incomplete endodontic therapy (D3332) for tooth 
#14, and a cone beam CT capture (D0364).