Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan.  
 
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 
physician's services to be provided by the requested provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown, core buildup, including any pins when required, 
and first intraoral periapical x-ray provided on June 23, 2020. 
 
You asked the Plan to pay for the crown, core buildup, and first intraoral periapical x-ray. You say that caps 
and crowns are very expensive, and you need additional help paying for these services. The Plan denied your 
request. The Plan says these procedures are not covered benefits under your dental plan. 
 
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. 
 
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 pay for the 
crown, core buildup, including any pins when required, and first intraoral periapical x-ray provided on June 23, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an admission to a SNF. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like to stay longer at the SNF 
because you need therapy. The Plan denied your request. The Plan says the SNF admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an admission to a SNF.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
provider is non-participating with this member's closed provider system.  There are participating providers 
within the member's provider system that can provide the requested services. 
 
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 items/services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's 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 enrollee is not able to care for himself and needs 
assistance in getting up from bed. The Plan denied your request. The Plan says the guidelines for coverage of 
IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional level requires an 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network pain management 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says a network gap does not exist. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network pain management provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with codes A6532 and 
A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that these stockings are medically 
necessary to keep the lymphedema from returning to your legs after your therapy sessions. Though these may 
not be covered by Medicare, you state that you have supplemental coverage with the Plan to cover things that 
Medicare does not. The Plan denied your request. The Plan says Medicare does not cover these stockings for 
your condition. Your Plan does not offer additional coverage for these items. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6532 
and A6533 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say 
that compression bandages and gradient compression wraps are covered only when they are used as dressings 
over a qualifying wound. 
 
 
 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.  
 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with codes 
A6532 and A6533.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #9. 
 
You asked the Plan to pre-approve the crown. You say that your tooth is sensitive, and you cannot eat or chew 
food. You also say that this service is medically necessary. The Plan denied your request. The Plan says that 
the crown for tooth #9 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 
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. Our reviewer says that this 
service is medically necessary. Our physician reviewer found replacement of the lost crown restoration on 
tooth #9 to return the tooth to normal function meets the criteria for coverage. 
 
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 have been met. Therefore, we decided that the Plan has to pre-
approve a crown (D2740) for tooth #9.  
 
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 admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received 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 above. 
 
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 there is a lack of medical and nursing needs. The enrollee is medically stable with 
debility from a recent acute illness. There is no documented evidence of medical issues that require monitoring 
by an inpatient rehab physician three times a week. The documentation does not support that there is a need for 
an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care at the current 
functional status. The enrollee's rehab needs can be met in an alternate, less intense setting such as in an SNF or 
in-home with 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional PT visits. 
 
You asked the Plan to pre-approve the 15 additional PT visits. The Plan denied your request. The Plan says the 
additional PT visits are not reasonable and 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 15 additional PT visits. 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 requested additional therapy is not generally 
accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for 
this condition and the documentation does not support that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment; that the services can be safely and effectively 
performed only by a therapist or under the supervision of a therapist. The enrollee has been authorized for 
additional therapy to transition to an independent home exercise program and the remaining therapy does not 
require the specialized skill, knowledge and judgment of a qualified therapist to establish, design and/or deliver 
a program to maintain the enrollee's 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 15 additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 15 additional PT visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brow defect repair. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence that an additional eyebrow repair is necessary to provide adequate 
improvement of vision. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the clinical documentation, which includes photographs, does not support that there is drooping of the 
eyebrows to such an extent that excess tissue is pushed into the upper eyelid, and would be contributing to 
significant superior visual field loss. The documentation by the provider noting that the enrollee "could still 
benefit functionally from ptosis repair of the lids and brows is insufficient to support that brow repair is 
medically reasonable and necessary for the enrollee 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve brow defect repair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lung cancer screening with low dose computed 
tomography. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says it has been over fifteen years since smoking has stopped. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found you quit smoking 18 
years ago. This scan is covered if you have quit smoking within the past 15 years, or is still smoking. For this 
reason, this scan is not covered. No CT report is included in the records. If there is indeed a desire to follow 
pulmonary nodules a diagnostic CT of the chest would be necessary and not a low dose lung CT for screening. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve lung cancer screening with low dose computed tomography.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a telephone alert system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 pre-approve a telephone alert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner (E1399). 
 
You asked the Plan to pre-approve the recliner. You say that the reclining chair is medically necessary. The 
Plan denied your request. The Plan says recliners are not a covered item. 
 
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 pre-approve a recliner (E1399).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says your conditions are chronic, and you have not had an acute illness. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing 
services with the specialized, knowledge, and judgement of a skilled professional nurse required to safely and 
effectively provide medically necessary and reasonable treatment in a SNF.  
 
 
There is no complex wound care, or other ongoing SNF level skilled nursing needs. The functional level does 
not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist 
to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy on a daily basis. As a practical matter, the services are not required on an 
inpatient basis, in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750) for tooth #'s 2 & 5 and pontics 
(D6240) for tooth #'s 3 & 4. 
 
You asked the Plan to pre-approve the retainer crowns and pontics. You say that the dentist wants you to pay 
$3,000 for these services. You also say that you do not have the $3,000 and would like the Plan to pay half. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the retainer 
crowns and pontics 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 retainer crowns and pontics. Our 
reviewer says that the services do not meet coverage criteria. Our physician reviewer found replacement of 
tooth #'s 3 and 4 (posterior teeth) with a fixed bridge do not meet the criteria for coverage. Our reviewer also 
found that according to the Plan, fixed bridges replacing anterior teeth are considered for coverage. 
 
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 retainer crowns and pontics have not been met. Therefore, we decided that 
the Plan does not have to pre-approve retainer crowns (D6750) for tooth #'s 2 & 5 and pontics (D6240) for 
tooth #'s 3 & 4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup, including any pins when required (D2950) 
and two retainer crowns (D6750 x2). 
 
You asked the Plan to pay for the core buildup and retainer crowns. You say that the enrollee has active 
periodontal disease and generalized pocket depth. The Plan denied your request. The Plan says these services 
are not covered. 
 
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. 
 
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 pay for a core 
buildup, including any pins when required (D2950) and two retainer crowns (D6750 x2).