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

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because the 
member would like to continue seeing this provider as they provide a prescription for free that the member 
would not be able to afford elsewhere. The Plan denied your request. The Plan says this request does not fit the 
definition of a medical emergency and the requested care is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you have a fracture from a fall. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for the enrollee, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta (Pegfilgrastim) injection (J2505). 
 
You asked the Plan to pre-approve Neulasta (Pegfilgrastim) injection. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is not supported for the enrollee's medical 
condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Neulasta (Pegfilgrastim) injection. Our 
reviewer says that the service is not medically reasonable or necessary. Our physician reviewer found the use 
of this drug is indicated for the treatment of nonmyeloid malignancies receiving myelosuppressive cancer 
chemotherapy associated with a clinically significant incidence of febrile neutropenia. This patient has a 
myeloid malignancy. There is no compendia support for patients with myeloid malignancy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta (Pegfilgrastim) injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Neulasta (Pegfilgrastim) injection (J2505).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of brain (70553) 
and computed tomography (CT) scan of chest (71250). 
 
You asked the Plan to pre-approve the MRI of brain and CT scan of chest. You say that you need these 
services. The Plan denied your request. The Plan says these services are not medically necessary. 
 
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 MRI of brain and CT scan of chest. 
Our reviewer says that these services are not medically necessary. Our physician reviewer found regarding the 
MRI of the brain, the reason for this order is not addressed in the clinical notes. There is no history of trauma 
and the neurology exam is unremarkable. You do complain of sleep disorder but the medical necessity of MRI 
of the brain is not addressed or explained in the records submitted. 
 
Regarding the CT scan of chest, the reason given for CT of the chest was given as "follow-up pulmonary 
nodules" and reference was given to CT scans of 2019 where six month follow-ups were recommended. 
However, the reports of the prior scans have not been included and the number, size, shape etc. of the 
referenced nodules cannot be commented upon in the determination of medical necessity of 6-month follow-up, 
if any.  Prior to approving diagnostic CT for nodule follow-up, the prior CT reports must be evaluated and 
matched with Fleischner criteria for appropriate follow-up. 
 
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 MRI of brain and CT scan of chest have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of brain (70553) and 
computed tomography (CT) scan of chest (71250).
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 this is medically necessary. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a resin-based composite (D2391), a crown (D2740), and a 
coronal structure buildup (D2950) received on September 21, 2020. 
 
You asked the Plan to pay for a resin-based composite, a crown, and a coronal structure buildup. You say that 
you feel you were charged unfairly and would like to know if the Plan can help you pay the bill a little more. 
The Plan denied your request. The Plan says rules for payment have 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 a resin filling 
or restoration at the rate of 1 procedure per year. 
 
In this case, the record shows that you received another resin-based composite on the same date of service. 
Your benefit for this service is exhausted for a year after September 21, 2020. Therefore, we decided that the 
Plan does not have to pay for a resin-based composite (D2391) received on September 21, 2020. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, a crown and a coronal structure 
buildup are not among the services covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for a crown (D2740) and a coronal structure buildup (D2950) received on September 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says movement to a skilled nursing facility 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for 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) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. 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 medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a seat lift mechanism. Our reviewer 
says that the documentation does not support that the requested seat lift mechanism is medically reasonable or 
necessary. Our physician reviewer found while the documentation does indicate that you are not able to 
ambulate, the documentation does not reveal that you have a neuromuscular disease. The documentation does 
not indicate that the seat lift mechanism is part of the treating medical practitioner treatment plan. The 
documentation does not support that a seat lift is likely to effect improvement in your condition or arrest or 
retard deterioration in your condition. The records do not indicate that you are completely incapable of standing 
from a chair in the home on a physical exam. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to an LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for teeth #11. 
 
You asked the Plan to pre-approve the crown for tooth #11. You say that the crown is medically necessary for 
the enrollee. The Plan denied your request. The Plan says porcelain crown is not listed as a covered service. 
 
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 
porcelain crown (D2740) for teeth #11.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis coded L1833 and the addition to lower 
extremity orthosis coded L2397 provided on September 5, 2020. 
 
You asked the Plan to pay for the knee orthosis and the addition to lower extremity orthosis. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation 
is missing required information. 
 
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 find that CPT codes L1833 and L2397 are not supported in the medical record. Specifically, the 
documentation does not support a claim for the ordering physician. The documentation does not support that 
the prescribing physician ever saw the enrollee. Based on this information, we decided that Medicare rules for 
coverage of the knee orthosis and the addition to lower extremity orthosis have not been met.  Therefore, we 
decided that the Plan does not have to pay for the knee orthosis coded L1833 and the addition to lower 
extremity orthosis coded L2397 provided on September 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interspinous process decompression 
device (22869, 22870). 
 
You asked the Plan to pre-approve the insertion of an interspinous process decompression device. You say that 
this is medically necessary. 
 The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of an interspinous process 
decompression device. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is 
needed to show safety and efficacy. 
 
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 insertion of an interspinous process decompression device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interspinous process 
decompression device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve vision services. You say that you would like to see this doctor because he 
has been your eye doctor for the last 35 years. 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 
vision services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator trial for the enrollee. 
 
You asked the Plan to pre-approve the trial. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation submitted of any recent imaging findings including an MRI of 
the lumbar spine. 
 
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 trial. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is not a late or last resort approach to the back pain. The request is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the trial have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a spinal cord stimulator trial for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require this level of care. The Plan denied your 
request. The Plan says that your care needs can be provided at a lesser level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to 
perform fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs 
can be met at a lower level of 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to 
the enrollee from December 23, 2020, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that this was court ordered. The Plan 
denied your request. The Plan says the stay is not necessary. 
 
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 
mental health care. Our physician reviewer found based upon review the records provided for the admission 
does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of 
December 23, 2020, forward as you were not shown to be a danger to yourself or others. You were not showing 
any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any 
threats the safety. 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 mental health care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to the 
enrollee from December 23, 2020, forward.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says your care is 
custodial in nature. 
 
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 continued services. Our physician 
reviewer found that you are at a contact guard assist level for walking using a rolling walker, and contact guard 
to minimum assist for transfers and activities of daily living. the records do not document any unstable medical 
conditions. There are no identifiable skilled nursing or therapy services. You do not require daily skilled 
services. You do not require necessary services 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.