Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown and core buildup services. 
 
You asked the Plan to pre-approve a crown and core buildup services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are 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. 
 
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.  The requested services are covered once per tooth every five years. 
Review of the file shows that you last received a crown on tooth 13 on July 12, 2018. Five years have not 
passed since your last crown on this tooth. Therefore, we decided that the Plan does not have to pre-approve a 
crown and core buildup services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Monovisc. 
 
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 Euflexxa. Our physician reviewer found 
that the enrollee has left knee osteoarthritis. The enrollee has not trialed a viscosupplemental treatment of 
Monovisc. Step Therapy, as outlined by the plan, requires that this be trialed first. The documentation does not 
outline contraindications or reasons this medication was not considered. Without the support of the 
documentation, Euflexxa is not approved as step criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laminectomy, facetectomy and foraminotomy (63048-59 x2) 
provided March 23, 2020. 
 
You asked the Plan to pay for two units of laminectomy, facetectomy and foraminotomy. You say that the 
services provided were medically necessary. The Plan denied your request. The Plan says the billed services 
are not supported for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 two units of laminectomy, facetectomy and 
foraminotomy. Our reviewer says that the billed services are not supported in the medical records. Our 
physician reviewer found in this case, the laminectomy is considered integral to the arthrodesis and is not 
reported separately. A code that included fusion and laminectomy, would have been a more appropriate 
procedure code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two units of laminectomy, facetectomy and foraminotomy have not been met. 
Therefore, we decided that the Plan does not have to pay for laminectomy, facetectomy and foraminotomy 
(63048-59 x2) provided March 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve 10 skilled nursing visits. You say that it would be beneficial for the enrollee 
to receive care in his home. The Plan denied your request. The Plan says these visits are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 10 skilled nursing visits. Our reviewer 
says that the requested visits are not medically necessary. Our physician reviewer found the records do not 
demonstrate that skilled nursing services are required to effectively provide treatment, care, and/or services in 
order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the his 
condition and/or prevent 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 10 skilled nursing visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 skilled nursing visits (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the plan does not have to pre-approve the office visits. 
 
You asked the plan to pre-approve the office visits. You say that services were medically necessary. the plan 
denied your request. the plan says services are non-emergent in nature. There are providers in-network that can 
provide the services in question. 
 
Medicare rules say that health 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 is not an in-network provider. 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 pre-approve office visits (99215) provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to be transferred to the inpatient rehab floor 
of the hospital instead of a nursing home due to Covid19. The Plan denied your request. The Plan says based 
on Medicare guidelines, the request for approval of an Inpatient Rehabilitation Facility admission does not 
meet the requirements for approval. 
 
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 that you do not require the intensity of services provided at an IRF. Specifically, you 
are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 
Your care needs can be met at a lower level of care such as a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. You 
are currently medically being treated for kidney failure. There is no evidence of complex medical issues that 
require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. 
While you may benefit from continuing physical therapy and occupational therapy, at your functional level 
there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent 
physician oversight and an interdisciplinary approach to rehabilitation care. Our physician reviewer found that 
your condition does not meet Medicare criteria for IRF 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-preferred diabetic testing supplies. 
 
You asked the Plan to pre-approve non-preferred items. The Plan denied your request. The Plan says the 
documentation does not show that the enrollee cannot use one of the preferred systems. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The rules say that plans 
may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or 
may limit the DME to only those preferred brands and manufacturers.  
 
The requested brand is not a preferred brand with the Plan. The Plan has preferred brands available for the 
services at issue in this appeal. We found no exception that would require the Plan to pre-approve a non-
preferred brand. Therefore, we decided that the Plan does not have to pre-approve non-preferred diabetic 
testing supplies.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99284) provided September 
20, 2019. 
 
You asked the Plan to pay for an emergency department visit. You say that the services provided were 
medically necessary and not related to an injury at work. The Plan denied your request. The Plan says there is 
not enough information in the medical records to overturn the denial. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 an emergency department visit. Our 
reviewer says that an emergency department visit (99284) is not supported by the medical records. Our 
physician reviewer found the documentation supports a detailed history and physical examination. The enrollee 
was diagnosed with fracture, tibia and fibula. A splint was applied. The documentation does not support 
medical decision making of moderate complexity. There were not multiple diagnoses or management options. 
 
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 emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for an emergency department visit (99284) provided September 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the occlusal guard. 
 
You asked the Plan to pre-approve the occlusal guard. You say that you had your previous guard for 30 years 
and really need a new one. 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 Plans 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 the 
occlusal guard.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like to out-of-network because 
you did not have success with the in-network doctor. The Plan denied your request. The Plan says there are in-
network providers available for these 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 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 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 17 more home skilled nurse visits. 
 
You asked the Plan to pre-approve home health services. You say that the skilled nursing visits are medically 
necessary because of the enrollee's worsening condition. The Plan denied your request. The Plan says that 
additional skilled nursing visits are not necessary at this time. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the service is medically necessary. Our physician reviewer found that this enrollee is receiving home 
health nursing services including wound dressing changes, diabetic education, and home exercise program 
facilitation. The nursing notes enclosed in this chart have been reviewed. The guidelines for home health 
skilled nursing are very specific. The skilled services performed are indeed treating this enrollees 
postoperative injury, certainly helping to improve the condition, most definitely maintaining the condition, and 
definitely preventing deterioration of the enrollees condition. The enrollee is noted to have an open wound 
with exposed bone. The enrollee is wearing a wound VAC. The home health nurse is providing patient 
education, facilitating home exercise programs, and performing necessary wound dressings. With the severity 
of the enrollees wound and fragile medical state, the remaining 17 home health nursing visits are 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 home health services have been met. Therefore, we decided that the Plan has to 
pre-approve the requested 17 additional home skilled nurse visits.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection of substance not including neurolytic or nerve destruction substances using imaging guidance or detailed pictures in the lower back area to treat or diagnose pain.

You asked the Plan to pre-approve these injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that injection services are only covered for certain indications.

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 these injection services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the documentation provided does not include a treatment plan with the spinal levels to be treated nor describes a number of levels that exceeds these limit. The requested injection is not supported as part of a series. The response to a prior injection should be evaluated before having another one. The documentation provided describes a request for a series of injections and, therefore, the requested injection is not indicated at this time. Therefore, the enrollee does not meet criteria for the requested 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 these injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve injection of substance not including neurolytic or nerve destruction substances using imaging guidance or detailed pictures in the lower back area to treat or diagnose pain.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee cannot get herself out of bed 
and needs care. The Plan denied your request. The Plan says the records do not show the enrollee is 
homebound. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that the enrollee is homebound. Therefore, we decided that the Plan does not have to 
pre-approve home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says this drug is not 
medically 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 Reblozyl. Our reviewer says that 
Reblozyl is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found 
that the enrollee has not received transfusions since July 2, 2020. Despite the declining hemoglobin, the 
requested use does not meet FDA or compendia uses for the drug. Therefore, the requested use is not medically 
reasonable and necessary. The requested use is not medically safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental core buildup with dental code D2950. 
 
You asked the Plan to pre-approve dental service. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because this service 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 Plans 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 
dental core buildup with dental code D2950.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Medical Alert System. 
 
You asked the Plan to pre-approve a Medical Alert System. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item 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 Medical Alert System.