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

 
We decided that the Plan does not have to pre-approve the stimulator implant removal (99499) to be provided 
by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the stimulator implant removal. You say that the services are medically 
necessary. The Plan denied your request. The Plan says there are network providers able to provide 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
stimulator implant removal (99499) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate intravenous sedation services. 
 
You asked the Plan to pre-approve dental sedation. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct, because these services are not 
covered by the 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 
moderate intravenous sedation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation with an oral surgeon. 
 
You asked the Plan to pre-approve the consultation with an oral surgeon. You say that your tooth is broken at 
the gum line and very painful. You say that it needs to be extracted. You say that your cardiologist advised that 
the tooth needs to be extracted because you have two stents in your heart and the bacteria from the bad tooth 
could be dangerous. The Plan denied your request. The Plan says the services being requested 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 coverage for these services is 
limited to those performed by a participating general dentist. You are asking for services from an oral surgeon 
and not a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve 
consultation with an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a footplate bracket, calf panel center mount, and calf 
pad covers requested using three units of code K0108. 
 
You asked the Plan to pre-approve the requested wheelchair accessories. You say that the requested items 
should be approved. The Plan denied your request. The Plan says approval was made for this wheelchair; 
however, several items were requested with code K0108 when these items have a valid HCPCS code to 
describe them. 
 
The Plan must follow Medicare rules. Medicare rules say that K0108 is used when there is no code that 
describes an item.  
 
In this case, there are three footplate codes that could be chosen. The use of the miscellaneous code is not 
appropriate when there is a valid code that describes an item. In addition, coverage cannot be approved for 
either K0108, or its correctly coded equivalent E0995, since calf pads/rests are included in the approval for the 
power wheelchair base. Therefore, we decided that the Plan does not have to pre-approve a footplate bracket, 
calf panel center mount, and calf pad covers requested using three units of code K0108.
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 is receiving appropriate in-patient acute 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 pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. There is no 
documentation provided necessitating admission to a LTACH. At the time of the request, the member?s status 
is stable and improving. The member is receiving medically necessary acute and/or critical 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 Plan. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Y-90 radioembolization for liver lesions associated with 
hemangioendothelioma. 
 
You asked the Plan to pre-approve the Y-90 radioembolization. You say that there is no systemic treatment that 
can treat these lesions. Radioembolization is the only viable option. The Plan denied your request. The Plan 
says this treatment is not supported for the enrollee's condition. 
 
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 Y-90 radioembolization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this review relates to a request for Y-90 liver radioembolization to treat a 75-
year-old woman with metastatic hemangioendothelioma in her liver and lungs. The NCCN Guidelines Version 
2.2020 Soft Tissue Sarcoma do not include y-90 radioembolization as a treatment option for soft tissue 
sarcomas. This reviewer did not find any supporting citations in a PubMed search. As such, Y-90 
radioembolization is not medically reasonable and necessary 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 the Y-90 radioembolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Y-90 radioembolization for liver lesions associated with 
hemangioendothelioma.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for 
ongoing SNF care. The Plan denied your request. The Plan says the enrollee does not meet the rules for 
coverage of SNF 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee 
is consistently ambulating more than 100 feet and tending to activities of daily living with minimal supervision.  
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the 
enrollee's condition.  The enrollee's care needs at this point are custodial and, as a practical matter, can be 
provided at a lower level of 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care for the enrollee. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the enrollee's heart rhythm was controlled with oral 
medications. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. The patient did not require a two-midnight stay in the hospital to address the urinary tract infection (UTI) 
and atrial fibrillation as she only required oral metoprolol, and while antibiotics were given she could have 
been monitored for benefit under observation. There was no signs or symptoms suggestive of a complicated or 
resistant case of UTI or atrial fibrillation to justify admission to the hospital. Our physician reviewer found that 
the enrollee's condition does not meet Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care 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 the enrollee has had a stroke and needs intensive 
rehabilitation right away. The Plan denied your request. The Plan says the denial of authorization for IRF 
service is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. While the 
enrollee may benefit from multiple therapies such as physical and occupational therapy, the documentation 
does not support that the enrollee's functional status or activity tolerance requires an intensive rehabilitation 
therapy program in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this drug is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Prolia is covered when the above 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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that a 2019 bone density test shows evidence of osteopenia, not osteoporosis. The enrollee is noted to take calcium with vitamin D. While her calcium level is within normal limits, there is no evidence that her vitamin D level has been assessed. There is no evidence that the enrollee has used and either been intolerant of or unresponsive to other forms of osteoporosis medication. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four endosteal implants (D6010 x4). 
 
You asked the Plan to pre-approve the endosteal implants. You say that the dental implants are medically 
necessary for the enrollee's mastication. The Plan denied your request. The Plan says this service is not a 
covered benefit under the enrollee's benefit package. 
 
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 four 
endosteal implants (D6010 x4).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that the enrollee was previously treated with a similar 
therapy; however, he had improved to stable disease for a period of 10 months. The Plan denied your request. 
The Plan says the denial of authorization for Tecentriq is correct, because studies have not proven that this drug 
is helpful when the enrollee has already tried a similar anti-PD-1 therapy drug but did not have a positive 
result. 
 
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 Tecentriq. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Tecentriq. Our physician reviewer found 
atezolizumab (Tecentriq) is approved by the Food & Drug Administration (FDA) for the first-line treatment of 
extensive-stage small cell lung cancer in adults (in combination with carboplatin and etoposide). However, the 
enrollee is receiving second-line treatment. In addition, the enrollee has progression of disease of liver 
metastases on prior PD-L1 therapy less than 6 months ago. There is no major drug compendia or Medicare-
approved medical journals that support use in this setting. Therefore, the Tecentriq 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 Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Tecentriq.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endocrinology, dietician, and GI consultations to be 
provided by out of network (OON) providers.. 
 
You asked the Plan to pre-approve the OON consultations. You say that you have tried to be treated in-network 
but these providers have been unable to help you. The Plan denied your request. The Plan says there are other 
in-network providers who should be able to address these issues. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 OON consultations. Our reviewer says that the requested OON 
consultations are not shown to be medically reasonable and necessary at this time. Our physician reviewer 
found the patient in this case is a 76 year old male with chronic diarrhea and weight loss for the past 3 years. 
He has had an extensive workup with his local former PCP, neurologist, endocrinologist, and 
gastroenterologist, however, no conclusive diagnosis was made and symptoms persist. A request for out of 
network nutrition (dietician), gastroenterology, and endocrinology consultation and treatment was made. The 
patient has not yet had a second opinion with each of these specialties in-network, which is reasonable to 
request as they should be equally qualified to review this patient's case. There was no clear indication for 
getting these second opinions out of network at this time. Therefore, the requests for consultations via the 
Clinic will be considered not 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 the OON consultations have not been met.  
 
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 the OON consultations. Therefore, we decided that the 
Plan does not have to pre-approve the endocrinology, dietician, and GI consultations to be provided by out of 
network (OON) providers at the Clinic.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different 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. Our 
physician reviewer found based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the 
medical records provided you do not require treatment in an intensive rehabilitation therapy program. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup for tooth #13 (dental code D2950). 
 
You asked the Plan to pre-approve core buildup. You say that you need this service to prevent the removal of 
your teeth. 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 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 
core buildup for tooth #13 (dental code D2950).