Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional twelve (12) aquatic therapy visits. 
 
You asked the Plan to pre-approve the additional twelve (12) aquatic therapy visits. The Plan denied your 
request. The Plan says an additional 12 aquatic therapy visits 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 twelve (12) aquatic 
therapy visits. Our reviewer says that skilled services are not medically necessary to restore or maintain 
function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the 
medical records provided there is no documentation that the requested therapy is generally accepted as specific 
and effective therapy for your condition. Based on the available records you appear to have improved with 
therapy. Further formal therapy at this point does not appear to be necessary to achieve significant 
improvement in your symptoms or functional status. Further utilization of your home exercise program appears 
appropriate at this point. Based on the medical records provided there is no documentation that the unique 
skills of a professional therapist are required 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. Based on the 
medical records provided there is no documentation that the specialized skill, knowledge and judgment of a 
qualified therapist is 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 twelve (12) aquatic therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an additional twelve (12) aquatic therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental drugs/medications for home use. 
 
You asked the Plan to pre-approve dental drugs. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because this is not covered by 
the Plan's dental benefits. 
 
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 pre-approve 
dental drugs/medications for home use.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services provided on 
May 6, 2020, through May 19, 2020. 
 
You asked the Plan to pay for the LTACH services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says your services could have been continued at an acute inpatient hospital level 
of 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 pay for 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 there is no evidence that the enrollee required services that were not available at the acute 
inpatient hospital.  As LTACHs and acute inpatient hospitals are licensed to provide the same level of care, 
there was no advantage in transferring the enrollee to the LTACH. 
 
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. Specifically, your care could have 
continued at the inpatient hospital, and therefore, the transfer to a long LTACH was not reasonable or 
necessary. Therefore, we decided that the Plan does not have to pay for long term acute care hospital (LTACH) 
services provided on May 6, 2020, through May 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy 1 mg injection (J9228). 
 
You asked the Plan to pre-approve Yervoy. You say that this service is not medically necessary. The Plan 
denied your request. The Plan says the request for this drug is not medically reasonable and necessary. 
 
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 Yervoy. Our reviewer says that the 
service is not medically necessary or reasonable. Our physician reviewer found the combination of Yervoy and 
Opdivo is indicated for the treatment of hepatocellular carcinoma (in combination with nivolumab) in patients 
who have been previously treated with sorafenib. It is not indicated for patients who have already progressed 
on check point inhibitors such as 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 Yervoy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Yervoy 1 mg injection (J9228).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on September 3, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for specialist services provided on September 3, 2020, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve filler injection. We decided that the Plan does not have to pre-
approve dermabrasion.  
 
You asked the Plan to pre-approve filler injection. You say that this is not a cosmetic procedure and no other 
treatments have succeeded. The Plan says that the denial of authorization for these services is correct, because 
these services are not medically necessary. 
 
We decided that the Plan has to pre-approve filler injections.  
 
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 filler injection. Our reviewer says that 
you meet the Medicare criteria for the requested dermabrasion. Our physician reviewer found injection of 
fillers to restore anatomy/repair sulcus at oral commissure is an appropriate treatment for chronic angular 
cheilitis that failed other treatments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of filler injection have been met. Therefore, we decided that the Plan has to pre-
approve filler injection.  
 
We also decided that the Plan does not have to pre-approve dermabrasion. 
 
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 dermabrasion. Our reviewer says that 
you do not meet the Medicare criteria for the requested dermabrasion. Our physician reviewer found 
dermabrasion is used for treatment of actinic cheilitis, but not for angular cheilitis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of dermabrasion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dermabrasion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat diagnostic medial branch block. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee had previous radiofrequency ablation, and it did not help pain. 
 
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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found if the prior RFA did not produce pain relief, then it is not medically reasonable or necessary to repeat the 
diagnostic blocks. 
 
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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a repeat diagnostic medial branch block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of root canal obstruction; non-surgical access 
#14, 15 (D3331). 
 
You asked the Plan to pre-approve treatment of root canal obstruction; non-surgical access #14, 15. You say 
that you need the services and want the procedures to be approved. The Plan denied your request. The Plan 
says the service is not a covered benefit 
 
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. Any service not listed in the 
Plan?s 2020 EOC is not covered. 
 
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. Specifically, the service requested is not listed in the Plan?s 2020 
EOC, and therefore, is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve 
treatment of root canal obstruction; non-surgical access #14, 15 (D3331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9945). 
 
You asked the Plan to pre-approve the occlusal guard. You say that you need a new mouth guard. The Plan 
denied your request. The Plan says this service is not covered under your benefit 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 pre-approve an 
occlusal guard (D9945).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies (K0553). 
 
You asked the Plan to pre-approve the CGM supplies. You say that the CGM supplies are medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors and supplies are 
covered when the enrollee is insulin-treated with multiple (three or more) daily injections of insulin.  
 
We looked at the file and Medicare rules. The record shows the enrollee is not insulin-treated. Based on this 
information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies (K0553).
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 necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 based on the medical records provided you do have a significant complexity of 
nursing and medical needs. You do require physical therapy and occupational therapy services but you do not 
appear to be able to participate in an intensive inpatient rehabilitation therapy program due to severe dyspnea. 
There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility due to your severe dyspnea with minimal 
exertion. 
 
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 services provided on March 5, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of services. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve secondary portable oxygen tanks. 
 
You asked the Plan to pre-approve the tanks. You say that this is medically necessary. The Plan denied your 
request. The Plan says replacement equipment may be medically necessary when your clinical status has 
changed, or when the equipment is not working and cannot be repaired. 
 
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 tanks. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you are concerned about dust in her barn damaging the POC and is requesting portable tanks to 
use in the barn.  Medicare does not cover duplicate durable medical equipment. You can take reasonable 
measures to prevent contamination, such as placing the portable oxygen concentrator on a cloth in the barn. 
 
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 tanks have not been met. Therefore, we decided that the Plan does not have 
to pre-approve secondary portable oxygen tanks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete mandibular denture. You say that you have some financial 
difficulties, and are requesting some coverage for the denture. The Plan denied your request. The Plan says this 
service is not covered under your 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 pre-approve a 
complete mandibular denture (D5120).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on September 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 77003 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 77003 is fluoroscopic guidance and localization of needle 
or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or 
subarachnoid) (List separately in addition to code for primary procedure). 
 
We find that CPT code 77003 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the imaging services rendered on September 9, 2020.
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 you do not meet the Medicare criteria for SNF coverage under the Medicare Part A 
benefit. 
 
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 based on the medical records provided 
there is no documentation that you require skilled nursing or skilled therapy services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse or qualified therapist is not required to safely and 
effectively provide medically necessary and reasonable treatment. You do not require the services on an 
inpatient basis, in a skilled nursing facility setting. Services in the home with home health or in a long-term 
care facility with part time services appear appropriate 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve these services. You say that you are completely incapacitated. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.