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 if is not admitted to rehabilitation it would cause the 
enrollee to not get back to prior function and result to other drastic measures which would leave to be unable to 
regain any function and therapy. The Plan denied your request. The Plan says the enrollee's records do not 
show the rehabilitation needs are complex and does not need an intensive team for your care. 
 
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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on January 19, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you called the dental practice and were told this 
was your third cleaning. You also say you were told you are supposed to only get two cleanings a year and 
were told you would probably end up paying $49. 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 periodontal maintenance was exhausted on dates of service May 26, 2022, and 
September 29, 2022. Therefore, we decided that the Plan does not have to pay for periodontal maintenance 
(D4910) provided on January 19, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that your office is conveniently located and it 
would be unfair for the enrollee to start treatment all over again. The Plan denied your request. The Plan says 
this provider is out-of-network with the Plan and the enrollee can be treated within the Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
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 based on the enrollees current condition and 
function.al deficits as well as their multiple comorbidities, their attending physicians has determined that 
enrollee meets full Inpatient Acute Rehab criteria. The Plan denied your request. The Plan says the request is 
not medically necessary, the services the enrollee needs can be provided safely in other settings, for example, a 
skilled nursing 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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: Testing
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the colonoscopy provided on November 15, 2022. 
We also decided that the Plan does not have to fully waive the copayment for the colonoscopy provided on 
November 15, 2022.  
 
You asked the Plan to waive the copayment for the colonoscopy. You say that this should have been covered as 
it was preventative. The Plan denied your request. The Plan says that this cost sharing was charged correctly. We decided that the Plan has to reduce the copayment for the colonoscopy.  
 
You have been asked to pay a $275 copayment for the colonoscopy. Based on the Plan contract you cannot be 
asked to pay more than $175 as surgery services were provided in an ambulatory surgical center and not an 
outpatient hospital facility. Therefore, we decided that the Plan has to reduce the copayment for the 
colonoscopy provided on November 15, 2022.  
 
We also decided that the Plan does not have to fully waive the copayment for the colonoscopy. 
 
You are responsible to pay a $175 copayment for the colonoscopy. This item/service falls within the outpatient 
surgery, including services provided at ambulatory surgical centers benefit category. 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 fully waive the copayment for the colonoscopy provided on November 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee arthroplasty (27447). 
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
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 total knee arthroplasty. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. There is no clear documentation of any 
physical therapy for the left knee. The most recent exam is noted from August 26, 2022, with no more recent 
exam to provide current findings and it was noted that the enrollee did not want surgery at that time. Also, the noted last viscosupplementation injection was August 11, 2022; more recent findings are needed to potentially 
support that the enrollee is ready to proceed with surgery. Additionally, viscosupplementation injections could 
have delayed benefits, so updated documentation would be needed to corroborate these injections remained 
without benefit. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the total knee arthroplasty (27447).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on December 12, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis code was billed correctly. The 
Plan denied your request. The Plan says the diagnosis codes should not be billed together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim at issue was billed with diagnosis codes S00.81XA and S01.81XA. Diagnosis code S00.81XA has 
an Excludes1 note that includes diagnosis code group S01, which means these codes cannot be reported 
together. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for the emergency room services provided 
on December 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lymphedema decongestive treatment. 
 You asked the Plan to pre-approve lymphedema decongestive treatment. You say that you need this therapy for 
cancer treatment. The Plan denied your request. The Plan says you have completed 29 treatments and do not 
show further improvement. 
 
The Plan follows Medicare rules. Medicare rules state that lymphedema decongestive treatment may be 
covered if 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 lymphedema decongestive treatment. 
Our reviewer says that you do not meet criteria for this service. Our physician reviewer found the records do 
not document clear objective evidence of improvement within the first week or 10 days of your therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lymphedema decongestive treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lymphedema decongestive treatment.
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 the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 
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 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may benefit from physical therapy 
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 an IRF admission and 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 services are medically necessary for the enrollee 
to improve overall function and to maximize functional mobility. The Plan denied your request. The Plan says 
the services the enrollees needs can be provided safely in another setting such as a skilled nursing facility, 
home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this is medically necessary and supported by strong 
science. The Plan denied your request. The Plan says this is experimental/investigational. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found magnetic resonance imaging (MRI) shows foraminal narrowing, the cause of the enrollee's back 
pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
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 suctioning to prevent 
aspiration pneumonia. You also say the enrollee needs occupational therapy and physical therapy. 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 that the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care hospital services that can safely be provided at the current facility until 
more appropriate for a lower level of care. 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 it would not be clinically advantageous.  
 
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 an ultra-lightweight wheelchair and accessories coded 
as K0005, E2213, E2211 and E2213, E2219, E0961, K0040, E0951, E2611, E0937, E0971, E0978, E2007 and 
E2603 
 
You asked the Plan to pre-approve the wheelchair. You say that you are requesting an appeal review for the 
denied manual wheelchair order. The Plan denied your request. The Plan says the enrollee does not meet the 
medically necessary criteria. 
 
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 wheelchair. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of stroke and weakness affecting primarily the right lower extremity 
and cannot functionally ambulate with a cane or walker due to the risk for falling. The enrollee requires a 
manual wheelchair for mobility in performing daily activities. However, it is unclear why the enrollee requires 
a custom ultralight manual wheelchair for mobility. The enrollee has 4/5 motor strength in the upper 
extremities and can still ambulate 85 feet with a cane and assistance. It is not clear why the enrollee cannot use 
a standard or lightweight manual wheelchair for mobility needs. Therefore, the ultralight manual wheelchair 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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ultra-lightweight wheelchair and accessories coded as K0005, E2213, E2211 and 
E2213, E2219, E0961, K0040, E0951, E2611, E0937, E0971, E0978, E2007 and E2603
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6065) for tooth #13, and 
a retainer crown (D6740) for tooth #11. 
 
You asked the Plan to pre-approve the dental services. You say that you do not understand why this is being 
denied. 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 D6065 and D6740 were exhausted with the approval of D6065 for tooth #6 and #12, 
and the approval of D6740/D6245 for tooth #10, #8. #9, and #7. Therefore, we decided that the Plan does not have to pre-approve an implant supported crown (D6065) for tooth #13, and a retainer crown (D6740) for tooth 
#11.
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 losing all your strength and have nobody 
home to assist you, you need help. The Plan denied your request. The Plan says your records do not show that 
you need an intensive team for your care. Services needed may be provided safely in a lower level of care. 
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.