Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a shower/bath transfer bench. 
 
You asked the Plan to pre-approve shower bench. You say that you have a prescription for this item. The Plan 
denied your request. The Plan says that the denial of authorization for this item is correct, because this item is 
not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower/bath benches are not covered items. 
However, the Plan has a bathroom safety benefit that goes beyond Medicare's coverage. The Plan covers 
shower/bath benches up to a $100 annual benefit limit. 
 
We looked at the file and Medicare rules. Although the requested transfer bench is not covered by Medicare, it 
is covered by the Plan's supplemental bathroom safety benefit up to a $100 benefit limit. A physician order has 
been submitted for this item; therefore, the request meets the Plan's coverage criteria if the item is supplied by 
the Plan's durable medical equipment supplier. Based on this information, we decided that the Plan's rules for 
coverage of shower bench have been met. Therefore, we decided that the Plan has to pre-approve a shower/bath 
transfer bench.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 38 additional visits for mental health services with a 
marriage and family therapist. 
 
You asked the Plan to pre-approve the services. You say that you are comfortable with this provider. The Plan 
denied your request. The Plan says this provider is not allowed to bill Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program.  
 
We looked at the file and Medicare rules. The requested provider is a marriage and family therapist. This type 
of provider is not eligible to enroll in the Medicare program. Services from providers who are not enrollee in 
the Medicare program cannot be approved for coverage  Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-
approve 38 additional visits for mental health services with a marriage and family therapist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested chiropractic services. 
 
You asked the Plan to pre-approve the chiropractic services. The Plan denied your request. The Plan says there 
is no additional clinical information provided as to why an in-network provider cannot be used or as to why the 
service must be provided by an out of network provider. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested chiropractic services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission for an electroencephalogram 
(EEG). 
 
You asked the Plan to pre-approve an inpatient admission. You say that this is medically necessary. The Plan 
denied your request. The Plan says it is not necessary for this service to be provided in an inpatient setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found based on the provided documentations, there was no unique clinical circumstances 
noted which would require acute care services in an inpatients during or after the EEG testing. Monitoring and 
medication adjustments should be able to be safely and effectively performed in the observation level of care, 
which was recommended by the Plan. The notes do not suggest at least a 2 midnight stay in the hospital would 
be needed in this case. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission for an electroencephalogram (EEG).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee 
from July 15, 2020 through July 26, 2020. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that notes did not say the member needed 
this much care and could have cared for at an outpatient program. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee in this case. It was not expected the enrollee would improve in a reasonable period of time beyond the 
dates in question as he was not showing any dangerousness to self or others, no auditory or visual 
hallucinations and no abnormal behaviors. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric 
hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee from July 15, 
2020 through July 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injections, diagnostic or therapeutic agent, paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar 
or sacral; single level. 
 
You asked the Plan to pre-approve injections, diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral; single level (64493). You say that the enrollee needs the injections. The Plan denied your request. The 
Plan says this procedure is considered experimental, investigational, or unproven. 
 
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 injections, diagnostic or therapeutic 
agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance 
(fluoroscopy or CT), lumbar or sacral; single level (64493). Our reviewer says that the requested services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 
already had a prior sacroiliac joint injection which the office note dated June 5, 2020 states provided over 50% 
relief. This request is for a repeat bilateral, "Sacroiliac joint MBB for possible SI joint RFA." The office note 
dated July 8, 2020 states that the enrollee is status post L4-L5 and L5-S1 fusion which helped radicular pain. 
The provided medical records do not document an adequate trial of conservative therapies. Coverage for the 
requested procedure, sacroiliac joint injection, based upon the submitted medical records is not medically 
reasonable and 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 Injections, diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) 
joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 
(64493) have not been met. Therefore, we decided that the Plan does not have to pre-approve injections, 
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with 
image guidance (fluoroscopy or CT), lumbar or sacral; single level.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Astigmatic Keratotomy. 
 
You asked the Plan to pre-approve Astigmatic Keratotomy. You say that you need this procedure but cannot 
afford it. The Plan denied your request. The Plan says benefit coverage cannot be provided for this service. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a AC IOL during 
cataract surgery, the enrollee will be responsible for the difference in cost between the AC IOL and a 
conventional IOL.  
 
While a AC IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a AC IOL. Therefore, we decided that the Plan does not have to pre-approve Astigmatic Keratotomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature. 
 
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that this feature is 
necessary to reach objects, have eye to eye contact with others, and raise and lower you. The Plan denied your 
request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan. 
 
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. A power seat 
elevation feature does not serve a purpose that is primarily medical in nature. This feature is not covered by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat 
elevation feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown for tooth #8. 
 
You asked the Plan to pre-approve the crown for tooth #8. You say that treatment should be approved. The 
Plan denied your request. The Plan says the service is 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 Plan?s coverage rules apply in this case. The Plan covers the crown for 
tooth #8 when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crown for tooth #8. Our reviewer 
says that the criteria for coverage has not been met. Our physician reviewer found that there does not appear to 
be significant coronal breakdown due to caries or fracture to warrant a crown restoration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown for tooth #8 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the crown for tooth #8.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that your medical conditions require 
transportation to this destination. The Plan denied your request. The Plan says that the denial of authorization 
for routine transportation is correct, because routine transportation to a destination beyond 75 miles of the 
pickup location is not covered by the Plan. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers routine transportation for up to 60 one-way trips per calendar year, limited to ground 
transportation only to destinations within 75 miles of the pickup location. 
 
We looked at your request, the records in the case file, and the rules. The requested destination is within 75 
miles of your pickup location. Based on this information, we decided that the Plan's rules for coverage of 
routine transportation have been met. Therefore, we decided that the Plan has to pre-approve routine 
transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing for all quadrants. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that the treatment would help 
mitigate further bone loss and periodontitis. You say that the proposed treatment should be approved. The Plan 
denied your request. The Plan says the criteria for coverage has not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers periodontal 
scaling and root planing 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 periodontal scaling and root planing. 
Our reviewer says that the criteria for coverage has not been met. Our reviewer says that there are less than four 
teeth per quadrant showing any loss of bone support, a key feature of periodontal disease. Our physician 
reviewer found that the x-rays appear to show full bone support around the teeth and no evidence of root 
surface calculus.  
 
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 periodontal scaling and root planing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve periodontal scaling and root planing for all quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee. 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered 
because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve 
a power seat elevation feature (E2300) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy. 
 
You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration 
because you fell and had a setback with your physical therapy progress. The Plan denied your request. The Plan 
says the additional physical therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional physical therapy. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the records do not indicate you require the unique 
skills of a professional therapist to safely and effectively provide treatment. The requested services are not part 
of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow 
further deterioration. 
 
 
 
 
 
 
 
 
 
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 additional physical therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need the requested shower chair because it 
is important for you to not have any accidents in the future when you are bathing. You say that sometimes you 
have slipped because you suffer from conditions that make you dizzy. You stated that your knees do not 
support you because you no longer have any cartilage. You asked the Plan to reconsider providing coverage 
because you say the requested item is necessary for your safety. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Rituxan (J9312). 
 
You asked the Plan to pre-approve Rituxan. You say that this is medically necessary and supported by clinical 
trials. The Plan denied your request. The Plan says that this is not supported for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Rituxan. Our reviewer says that 
Rituxan is considered reasonable and necessary for this patient. Our physician reviewer found the patient has 
idiopathic nonspecific interstitial pneumonia (NSIP,) and has had significant progression of the disease despite 
initial treatment with systemic steroids and mycophenolate. The patient now has very severe restrictive lung 
disease with secondary pulmonary arterial hypertension and chronic hypoxic respiratory failure. Rituximab has 
been used with success in some patients with NSIP associated with connective tissue disease. It is indicated in 
patients who have failed corticosteroids and another immunosuppressive agent, as this patient has. There have 
been no large randomized trials in idiopathic NSIP. Nevertheless, considering the lack of better alternatives, 
this treatment is reasonable and necessary for this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have been met. Therefore, we decided that the Plan has to pre-approve 
Rituxan (J9312).  
 
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 a referral to an out-of-network dentist. 
 
You asked the Plan to pre-approve these services. You say that you've had an ongoing relationship with this 
provider for years. The Plan denied your request. The Plan says the provider is not within the network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental 
services from providers within the network only.  
 
We looked at the file and the Plan's rules. The file shows that the requested dentist is not a network provider 
with the Plan. Based on this information, we decided that the Plan's rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network 
dentist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ilumya. Our reviewer says that the 
enrollee has not trialed Stelara. Step therapy, as outlined by the plan, requires these be trialed first. Our 
physician reviewer found the documentation does not outline contraindications or reason Stelera was not 
considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).