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

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that the in-network provider is too far 
from your location. The Plan denied your request. The Plan says the services are available from a network 
provider. 
 
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. The in-network provider is a tertiary 
facility equipped to provide the same level of care as the requested out-of-network provider. The file shows 
that the in-network provider is located 23 miles from your residence, which is within the accepted accessibility 
distance for Medicare. 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 a referral to an out-of-network provider.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with acute respiratory failure, acute respiratory distress syndrome, COPD exacerbation, 
and COVID pneumonia. He was diagnosed with a gastrointestinal bleed, altered mental status, and acute 
kidney injury. He does not require services at the LTACH that are not already available at the current facility. 
There are no services at the LTACH that the patient requires that are not available and covered at the current 
facility. LTACH services are not medically necessary at this time. 
 
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, core buildup, and prefabricated post 
and core. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has an active infection. The 
Plan denied your request. The Plan says the 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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain 
crown, core buildup, and prefabricated post and core.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs a higher level of care 
due to COVID status. The Plan denied your request. The Plan says the enrollee is asymptomatic without fever 
and does not required daily skilled 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 admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male who was 
transferred from an assisted living facility on 9/26/2020 due to COVID-positive status. He appeared to be 
asymptomatic at admission and has remained afebrile on room air with no respiratory symptoms or other acute 
instability in the nursing facility. There is no indication in the records that he has required any physical or 
occupational therapy. He is forgetful but in no distress; his functional status is not defined. He has required no 
intravenous medication and no acute medication changes have been documented.  
 
There is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide 
medically necessary and reasonable treatment.  
 
There is no evidence of the need for skilled therapy services. Based on the medical records provided, this 
patient does not require the services on 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure nutritional supplements. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. These items are not covered by 
Medicare or the enrollee's plan. Therefore, we decided that the Plan does not have to pre-approve Ensure 
nutritional supplements.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation on teeth 
#30 and #31. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 bone 
replacement graft for ridge preservation on teeth #30 and #31.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the CT of abdomen and pelvis. We decided that the Plan does not 
have to pre-approve the CT thorax.  
 
You asked the Plan to pre-approve the CT scans. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 CT scans.  
 
We decided that the Plan has to pre-approve the CT of abdomen and pelvis.  
 
Our physician reviewer found the Plan should pre-approve the CT abdomen/pelvis to workup for progression. 
Therefore, we decided that the Plan has to pre-approve the CT of abdomen and pelvis.  
 
We also decided that the Plan does not have to pre-approve the CT thorax. 
 
Our physician reviewer found the Plan should not pre-approve the CT thorax because it is not recommended. 
Therefore, we decided that the Plan does not have to pre-approve the CT thorax. 
 
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 a Mirena intrauterine device (IUD). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers specific preventive services only. 
 
We looked at the file and Medicare rules. The services at issue are an IUD for contraceptive purposes. This is a 
preventive service that is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-
approve a Mirena intrauterine device (IUD).  
 
Benefits for these services 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require two therapy disciplines, or physician supervision 3 times a week. 
 
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 physician reviewer found 
that the enrollee is at a moderate assist level for bed mobility and standing up, minimal assist for grooming, 
standby assist for eating, and moderate to maximal assist for dressing. The enrollee does not require the 
intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per 
week of rehabilitative services and regular physician evaluation. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the services can be rendered in a different setting. 
 
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 therapy 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not require daily skilled nursing or therapy services. 
 
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 physician reviewer 
found that from a nursing perspective, the enrollee had stable vital signs. She had no signs of respiratory 
illness, cough, or shortness of breath. There are no identifiable skilled nursing service needs. Regarding rehab 
services, the enrollee did not receive or require any skilled therapy. She 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 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil 5 MG tablet. 
 
You asked the Plan to pre-approve the tablet. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tadalafil 5 MG tablet.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent transportation. 
 
You asked the Plan to pre-approve non-emergent transportation. You say that the enrollee needs supervision 
during transportation. The Plan denied your request. The Plan says the enrollee is not shown to be bed 
confined. 
 
Medicare pays for ambulance services only when the beneficiary be bed-confined. The Plan follows the same 
rules.  
 
We looked at the file and Medicare rules. The record does not show that the enrollee is bed-confined. Based on 
this information, we decided that Medicare rules for coverage of non-emergent transportation have not been 
met. Therefore, we decided that the Plan does not have to pre-approve non-emergent transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of surgical treatments, or records to show being a surgical 
candidate. 
 
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 surgery. Our reviewer says that the 
requested stimulator is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presents with chronic low back pain radiating into the right lower extremity. Clinical exam 
findings did not evidence a focal neurologic deficit. There is reported imaging evidence of severe lumbar 
central and neuroforaminal stenosis. She has failed to achieve sustained improvement with conservative 
treatment, including medications, epidural injections, and physical therapy. She is not indicated for urgent 
surgical referral as there is no strength deficit, and she wants to avoid surgery if possible. Under consideration 
is a request for spinal cord stimulator trial. Medicare criteria have not been met. The enrollee does not have a 
covered indication to support this request as medically necessary consistent with the Medicare LCD L35450 
criteria. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of skin lesions. 
 
You asked the Plan to pre-approve removal of skin lesions. You say that the cyst causes you pain and anxiety. 
The Plan denied your request. The Plan says your treating dermatologist needs to provide better documentation.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that providers must produce medical records to support medical 
necessity. 
 
We looked at the file and Medicare rules. There is no documentation of a description of the lesion, location, 
symptomatology or definitive diagnosis. Based on this information, we decided that Medicare rules for 
coverage of removal of skin lesions have not been met. Therefore, we decided that the Plan does not have to 
pre-approve removal of skin lesions.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical/thoracic facet joint radiofrequency neurolysis 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says services that are not medically necessary are not covered under the health benefit plan. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found facet blocks need to be performed at the medial branch nerve, not intra-articular; and it was not specified 
which was done. The procedure note was not enclosed to evaluate which approach was used. In this case, given 
the medical records provided for review, there is no specific documentation indicating that the facet joints are 
the source of the pain. In addition, there been no documentation of failure of conservative treatment. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical/thoracic facet joint radiofrequency neurolysis for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as an acute rehab 
facility, skilled nursing facility, nursing facility, outpatient setting, or home 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. Our 
physician reviewer found it appears that the enrollee is improving, but requires additional short-term acute care 
services until more stable for discharge. The enrollee does not require services at the LTACH that are not 
already available at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Ongoing care at the current facility appears most appropriate. Transfer to a 
lower level of care may be considered soon. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT Code 63650 X4) and implantable neurostimulator electrode, each (CPT Code L8680 
X16). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our physician reviewer 
found you only underwent a web based screening for your psychological evaluation. This is distinct from a 
formal psychological evaluation which is a requirement per the NCD for coverage of a spinal cord stimulator 
(SCS) trial. In this setting, the requirements for coverage cannot otherwise be said to have been met at this 
time. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650 
X4) and implantable neurostimulator electrode, each (CPT Code L8680 X16).