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

We decided that the Plan does not have to pay for the periodontal maintenance provided on June 15, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that this service should be covered as a 
basic restorative service, and should be covered. The Plan denied your request. The Plan says this procedure is 
considered a diagnostic/preventive service, and is allowed once per year. 
 
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, one routine cleaning in a calendar year. 
The record shows that you received periodontal maintenance on February 11, 2020, and your cleanings benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance 
provided on June 15, 2020.  
 
Your complaint about your disappointment with the Plan is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency denervation in the lower back. 
 
You asked the Plan to pre-approve Injection, anesthetic agent(s) and/or steroid; nerves innervating the 
sacroiliac joint, with image guidance (64451). You say that you need the injection for your chronic back pain. 
The Plan denied your request. The Plan says sacral nerve branch blocks are experimental and investigational. 
 
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 Injection, anesthetic agent(s) and/or 
steroid; nerves innervating the sacroiliac joint, with image guidance (64451). Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/investigational because of the wide variation in efficacy 
reported in the peer reviewed literature. Therefore, 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 Injection, anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac 
joint, with image guidance (64451) have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency denervation in the lower back.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 13, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
physicians services. 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 April 13, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve lancets and test strips for high utilization testing. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that diabetic testing supplies for high utilization 
testing are covered when specific 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the submitted records show that you have 
insulin-dependent diabetes with a hemoglobin A1C level of over 12 percent. You have uncontrolled diabetes 
that requires more frequent checking of your blood sugar levels. The high utilization testing supplies are 
reasonable and medically necessary due to the complicated nature of your diabetes diagnosis. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve lancets and test strips for high utilization testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services required exceed the clinical capabilities of lower levels of care.The Plan denied your request. The Plan says the enrollee does not need daily doctor visits, or specialized nursing 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 physician reviewer found that the enrollee was admitted to the current acute care hospital for repeat sternotomy with aortic root replacement. Following the surgery, he was hypoxic and requiredongoing mechanical ventilation, and was treated for bacteremia. He received a trach and PEG, however, was able to wean down to oxygen supplementation only. His current needs are ongoing nutrition support, physical and occupational therapy, basic wound care, and oxygen weaning.The enrolleeappears to be stabilizing and improving. However, additional short-term acute care services is needed,which is likely to take less than 25 additional days,and can safely be completed at the current facility. The enrolleedoes not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACHservices 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 LTACH services have not been met.Therefore, we decidedthat the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to hold you harmless for an MRI of the brain (70551), a CT scan of the head and brain (70450), a chest X-ray (71045), and an ultrasound of extracranial arteries (93880) performed.

You asked the Plan to hold you harmless for an MRI of the brain, a CT scan of the head and brain, a chest X-ray, and an ultrasound of extracranial arteries. You say that the responsibility for the cost of these services should not fall on you. The Plan denied your request. The Plan says that rules for coverage have not been met.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

You were referred for an MRI of the brain, a CT scan of the head and brain, a chest X-ray, and an ultrasound of extracranial arteries by a contract provider. The file does not show that the Plan provided notice that an MRI of the brain, a CT scan of the head and brain, a chest X-ray, and an ultrasound of extracranial arteries would not be covered. Under Medicare rules, this means an MRI of the brain, a CT scan of the head and brain, a chest X-ray, and an ultrasound of extracranial arteries is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for an MRI of the brain (70551), a CT scan of the head and brain (70450), a chest X-ray (71045), and an ultrasound of extracranial arteries (93880) performed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plasma rich platelet injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has osteoarthritis of the hip and the provider has requested platelet rich plasma 
therapy. The results of this therapy in literature are not clear on effectiveness. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve plasma rich platelet injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided to the enrollee from February 14, 2020 to February 15, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that this claim should be paid.The Plan denied your request. The Plan says insufficient medical records were submitted to show the enrollee required an inpatient level of care.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. The medical records provided do not clearly demonstrate a need for the enrollee to be admitted as an inpatient as opposed to having been kept in observation. The enrollee was released within 24 hours. Medicare rules for coverage of inpatient admission are not met. Therefore, the Plan does not have to pay forthe acute inpatient hospital care provided to the enrollee from February 14, 2020 to February 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on June 23, 
2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that the services were rendered 
by an in-network provider. The Plan denied your request. The Plan says the benefits for this service have been 
satisfied and the frequency limitation has been exceeded. 
 
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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on June 23, 
2020, which was covered by the Plan, and your intraoral x-rays benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on June 23, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on 
January 8, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that medically necessary services were rendered in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-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 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99310) 
provided on January 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 19, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
physician?s services. 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 June 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the injections of pain numbing substance into the lower back or tailbone 
spinal nerves. You say that you cannot wait anymore because you are in too much pain, and you do not want to 
be in surgery. The Plan denied your request. The Plan says the provider you requested these services to be 
rendered by is not part of your health plan. The Plan also says that you are required to use providers that are a 
part of your health 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 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 OON provider.
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 admission to a SNF. You say that SNF care is appropriate for the enrollee's 
condition. The Plan denied your request. The Plan says the rules for SNF care have not been met. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the member does not require skilled 
nursing and/or skilled therapy services on a daily basis.  She is medically stable and can receive further rehab 
services at a lower level of care.  Although further rehab services would be appropriate to improve function, as 
a practical matter, the daily skilled services can be provided at a lower level of care than a skilled nursing 
facility. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF 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: 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. You say that the medical complexity of the enrollee's case, along 
with the acute rehab needs, cannot be managed in a lower level of care. The Plan denied your request. The Plan 
says the IRF services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy 
program. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee will benefit from acute rehab to optimize her level of functioning prior to returning home. You also say that you believe an acute rehabilitation setting is the appropriate level of care.The Plan denied your request. The Plan says the enrollee does not meet the medical criteria for an IRF admission.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 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. Our reviewer found that the enrollee's care needs can be met 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 IRF care have not been met.Therefore, we decided thatthe Plan does not have to pre-approveacute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued SNF care.You asked the Plan to pre-approvecontinued SNF care. The Plan denied your request. The Plan says the services you need no longer meet Medicare guidelines to be given in a SNF.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 SNF care. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says there is no 
support for the enrollee needing daily skilled nursing interventions that are not available at the short term 
custodial level. 
 
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 the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. 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 a SNF admission.