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

We decided that the Plan does not have to pay for the medical services provided on August 13, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that there is no doctor in the medical center more 
qualified to work on your eyes. The Plan denied your request. The Plan says you have no out-of-network 
benefits. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided on August 13, 2020 by an out of network 
(OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is unsafe for discharge home. The 
Plan denied your request. The Plan says that this patient would be equally well served at an alternative level of 
care. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that you would like a trip over sixty miles. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation up to 60 miles one-way per trip. 
 
We looked at your request, the records in the case file, and the rules. The requested trip is over 60 miles. This 
cannot be covered. Based on this information, we decided that the Plan's rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220), personal protective equipment 
(D1999), and the surgical extraction of tooth roots (D7250) provided on November 18, 2020. 
 
You asked the Plan to pay for the dental services. You say that you know that you have an allowance towards 
tooth extractions. You say that you want to know why the allowance was not applied. You say that you believe 
a tooth extraction is a tooth extraction. You also say that the extraction was necessary. The Plan denied your 
request. The Plan says the periapical x-ray is not listed as a covered service. The Plan says that personal 
protective equipment is not listed as a covered service. The Plan also says that the surgical extraction 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. The record shows that you signed a payment agreement which shows 
that you agreed to be responsible for all services rendered that are not covered by your insurance. Therefore, 
we decided that the Plan does not have to pay for the periapical x-ray (D0220), personal protective equipment 
(D1999), and the surgical extraction of tooth roots (D7250) provided on November 18, 2020.
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 need therapy. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the submitted records show that 
you were admitted to the hospital on January 18, 2021. You had a stent placed on January 19, 2021. The 
progress note on January 26, 2021 states you have no issues and are ready for discharge. You do not require the 
intensity of services in an IRF. Specifically, you do not need 15 hours per week of rehabilitation services and 
regular physician evaluation. IRF services are not reasonable or medically 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 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 long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee can safely receive this care in another setting at 
this time. 
 
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. The enrollee 
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. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 10, 2020. 
 
You asked the Plan to pay for 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 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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on August 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra 30 mg/ml inj. 
 
You asked the Plan to pre-approve Fasenra. You say that these services are medically necessary. The Plan 
denied your request. The Plan says the service is not covered under Medicare Part B and is covered under the 
pharmacy benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Fasenra 30 mg/ml inj.  
 
Benefits for Fasenra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve human leucocyte antigen (HLA) testing. 
 
You asked the Plan to pre-approve the requested testing. The Plan denied your request. The Plan says the 
records do not show an elevated C-Reactive protein, abnormal x-rays of the iliosacral spine, or back pain that 
started at an early age. 
 
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 requested testing. Our physician 
reviewer found that the discovery of the link between HLA-B27 and a large family of inflammatory rheumatic 
diseases was one of the seminal advances in rheumatology in the last century. New ways to employ HLA-B27 
as a diagnostic and prognostic aid continue to emerge. In this case, there is no documentation of suspected 
ankylosing spondylitis. The records do not show that the results of the testing will be used to determine a 
specific diagnosis or treatment strategy. Therefore, the requested testing is not medically reasonable or 
necessary to treat the enrollee's condition. 
 
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 requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve human leucocyte antigen (HLA) testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic facet joint injection. 
 
You asked the Plan to pre-approve the requested injection. You say that the enrollee should be allowed this 
treatment to determine whether there is facet joint pain. The Plan denied your request. The Plan says there is 
not sufficient evidence to support this pain is generated by the facet joints. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions may be covered when the 
above referenced criteria 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 the requested injection. Our reviewer 
says that the requested treatment is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient has documented radiculopathy on electromyography testing as well as 
multiple other probable pain generators. As such, she does not meet the criteria of the LCD. The request is 
considered 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 requested injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a diagnostic facet joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310) and a surgical extraction 
(D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that your dentist recommended you see an oral 
surgeon. You also say that you need to have the tooth extracted due to medical reasons. The Plan denied your 
request. The Plan says dental services must be performed by a participating general dentist in order to be 
covered. The Plan also says that services that you receive from an oral surgeon 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. The Evidence of Coverage clearly states that services must be 
performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve 
a consultation (D9310) and a surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup. You say that you need this service. The Plan denied your 
request. The Plan says this service is 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 pre-approve core 
buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medication Euflexxa (J7323). 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the 
Plans denial. The Plan denied your request. The Plan says the enrollee has not met the required step therapy 
criteria as she has not tried and failed the medications Orthovisc and 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 this medication. Our reviewer says that 
the enrollee does not meet criteria for coverage of this medication. Our physician reviewer found that based on 
the medical records provided the enrollee has not tried and failed the required drugs. Additionally, there is no 
indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the medication Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services with CPT code S9374 
provided from February 29, 2020 to March 5, 2020. 
 
You asked the Plan to pay for CPT code S9374. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 looked at the file and Medicare rules. In this case, CPT code S9374 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for the home infusion therapy services with CPT code S9374 provided from February 29, 2020 to March 
5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy without 
facetectomy/foraminotomy/discectomy 1/2 segments (63005), one interspace lumbar (63030) and laminectomy 
with removal abnormal facets lumber (63012) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the requested service is supported when you have had 6 weeks of treatment 
given by your doctor which did not help. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documentation of adequate conservative measures to include physical therapy. There are no red flags for 
immediate surgery. More conservative measures are needed. Our physician reviewer found that the enrollee's 
condition does not meet criteria for these 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laminectomy without facetectomy/foraminotomy/discectomy 1/2 segments (63005), one 
interspace lumbar (63030) and laminectomy with removal abnormal facets lumber (63012) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard for teeth grinding (D9944). 
 
You asked the Plan to pre-approve the dental item. You say that the dental item is necessary. The Plan denied 
your request. The Plan says the occlusal guard 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 an 
occlusal guard for teeth grinding (D9944).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve a continuation of SNF services. You say that the records provided support 
the need for continued SNF care. The Plan denied your request. The Plan says the enrollee is appropriate for a 
lower level of care such as home health or outpatient therapy. 
 
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 a continuation of SNF services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received 
oral medications and had stable vital signs. The enrollee received physical therapy and occupational therapy in 
the SNF. The enrollee was at a supervision/stand by assist to contact guard assist level for functional mobility, 
including gait to 20 feet. The enrollee required varying assist with activities of daily living. There are no 
identifiable daily skilled nursing or daily skilled rehabilitation needs for the enrollee. The enrollee does not 
meet the severity of illness or intensity of service criteria for a SNF stay. 

 
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 continuation of SNF services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the lumbar spine for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records sent for review do not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the criteria for an MRI 
is not met. More conservative measures, including physical therapy, are needed. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the lumbar spine for the enrollee.