Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that you have 
used the 100-day SNF benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that more than 60 days passed from your discharge on April 24, 2020, to your new admission on 
July 10, 2020. This means that you are eligible for a new benefit period because you had not been receiving 
care in a hospital or skilled care in a SNF for more than 60 days in a row. Based on this information, we 
decided that Medicare rules for coverage of SNF services have been met. The Plan must continue coverage for 
the SNF skilled service until such time as you no longer need the service and proper notice has been issued, or 
the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued 
skilled nursing facility (SNF) services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (E0466). 
 
You asked the Plan to pre-approve a non-invasive ventilator. You say that you need this. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ventilators are covered for neuromuscular diseases, 
thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary 
disease. 
 
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 non-invasive ventilator. Our reviewer 
says that the requested ventilator is not medically necessary. Our physician reviewer found you have been 
recently hospitalized for acute-on-chronic hypercarbic respiratory failure due to multiple factors. Your 
diagnosis of chronic obstructive pulmonary disease (COPD) is not confirmed with pulmonary function testing. 
Your needs would be most appropriately met with Bilevel Positive Airway Pressure (BiPAP) at night. There is 
no evidence of BiPAP failure. Medicare does not cover a home ventilator when used as BiPAP.  Medicare also 
does not cover a home ventilator in the treatment of obesity hypoventilation syndrome. 
 
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 non-invasive ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a non-invasive ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
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 covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan covers 
hearing aids under the Medicaid portion of your contract. 
 
We looked at the file and the Plan's rules. The Plan covers hearing aids under the Medicaid portion of your 
Plan, not Medicare. Hearing aids are not covered by Medicare. Therefore, we decided that the Plan does not 
have to pre-approve hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says there 
was no documentation of a medical emergency and the services are available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair. You say that you believe this was denied in error. The 
Plan denied your request. The Plan says the denial of authorization for this item is correct, because durable 
medical equipment is not separately covered when you are a patient in a skilled nursing facility. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment is not separately 
covered when the enrollee is a patient in a skilled nursing facility.  
 
We looked at the file and Medicare rules. You are currently a patient in a skilled nursing facility; therefore, the 
Plan may not separately cover the requested power wheelchair. Your skilled nursing facility should provide 
needed durable medical equipment during the duration of your stay. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 3 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two endosteal implants (D6010 x2) and two custom 
fabricated abutments (D6057 x2). 
 
You asked the Plan to pre-approve the endosteal implants and custom fabricated abutments. The Plan denied 
your request. The Plan says these services are not covered 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 Plans 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 two 
endosteal implants (D6010 x2) and two custom fabricated abutments (D6057 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve radiofrequency ablation services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 radiofrequency ablation services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have chronic low back pain and sacro-ilitis bilaterally. You have had 
physical therapy, medication trials, and sacroiliac joint injections. The requested services are considered an 
experimental/investigational procedure due to the wide variation in efficacy in the peer-reviewed literature. 
Therefore, you do not meet criteria for the requested 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 radiofrequency ablation services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve botox injections. 
 
You asked the Plan to pre-approve botox injections. You say that the requested botox injections are medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested 
botox injections. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 botox injections. Our reviewer says that 
the requested botox injections are medically necessary. Our physician reviewer found the review indicates that 
the enrollee is with a history of chronic migraine and tension headaches, insomnia and depression. She has tried 
multiple medications over the last several years, recently received Ajovy (CGRP or calcitonin Gene Related 
Peptide antagonist) and was given Nurtec samples (CGRP medication) at her last Neurology visit. The 
enrollee's neurologist has recommended Botox therapy. 
 
The review has determined that the enrollee has a covered indication for the requested Botox per the LCD. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of botox injections have been met. Therefore, we decided that the Plan has to pre-
approve botox injections.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services for 14 hours per week. 
 
You asked the Plan to pre-approve the home health aide services. The Plan denied your request. The Plan says 
the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that the requested home health aide services are not medically reasonable and necessary. Our 
physician reviewer found that the enrollee did not have hands-on personal care needs documented in the 
records that required a home health aide to maintain his health. There are also no identifiable skilled nursing or 
rehabilitation needs documented. 
 
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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services for 14 hours per week.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested orthognathic surgery with face bone 
grafting, lower jaw grafting and other oral surgical procedures. 
 
You asked the Plan to pre-approve the requested oral surgery. You say that this is a medical condition which 
requires surgical intervention. The Plan denied your request. The Plan says this is being requested using 
incorrect codes to make it appear as if it is a medical procedure when this is simply a dental procedure to 
prepare the jaw for implants which is dental in nature and not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare also does not cover dental services, as defined 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 the requested oral surgery. Our 
reviewer says that the requested procedures are not considered medical in nature. Our physician reviewer found 
the enrollee is a 66-year-old woman with a diagnosis of Other dysphagia. She complains of severe pain and 
generalized discomfort of both her upper and lower jaws. It is documented that the enrollee's partial edentulism 
has caused atrophy of the bone and abscesses, affecting mastication with resultant digestive and nutritional 
problems. Dentures are not an option due to irritation to the enrollee, a hyperactive gag reflex, and existing 
bone atrophy. 
 
The requested procedures are for the care, treatment, filling, removal or replacement of teeth or structures 
directly supporting the teeth, and not primarily in regard to a medical 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 oral surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the requested orthognathic surgery with face bone grafting, lower jaw 
grafting and other oral surgical procedures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a two dimensional (2D) oral/facial photographic image 
(D0350), diagnostic casts (D0470), endodontic therapy of a premolar tooth (D3320), endodontic therapy of a 
molar tooth (D3330), four core buildups, including any pins when required (D2950 x4), and prefabricated post 
and core in addition to crown (D2954). 
 
You asked the Plan to pre-approve the 2D oral/facial photographic image, diagnostic casts, endodontic therapy 
of a premolar tooth, endodontic therapy of a molar tooth, core buildups, and prefabricated post and core. You 
say that the enrollee requires immediate treatment on these teeth. You also say that the enrollee cannot afford 
these services. The Plan denied your request. The Plan says 2D oral/facial photographic image, diagnostic 
casts, endodontic therapy of a premolar tooth, and endodontic therapy of a molar are not covered under the 
enrollee's plan. The Plan also says that core buildup and prefabricated post and core are only covered in 
conjunction with a crown, and there is no supporting documentation showing a crown will be performed with 
these services. 
 
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, 2D oral/facial photographic image, 
diagnostic casts, endodontic therapy of a premolar tooth, and endodontic therapy of a molar tooth are not 
among those covered under this benefit.  
 
 
 
Core buildup, including any pins when required (D2950) and prefabricated post and core in addition to crown 
(D2954) are covered benefits, but must be performed together with a crown. Therefore, we decided that the 
Plan does not have to pre-approve a two dimensional (2D) oral/facial photographic image (D0350), diagnostic 
casts (D0470), endodontic therapy of a premolar tooth (D3320), endodontic therapy of a molar tooth (D3330), 
four core buildups, including any pins when required (D2950 x4), and prefabricated post and core in addition to 
crown (D2954).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a BiPAP rental for 99 months. 
 
You asked the Plan to pre-approve a BiPAP rental for 99 months. You say that the enrollee needs a BiPAP. 
The Plan denied your request. The Plan says they will approve 3 months of rental and then there must be a 
clinical re-evaluation to continue the rental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. A re-evaluation must be conducted by the third month of rental. 
Based on this information, we decided that Medicare rules for coverage of a BiPAP rental for 99 months have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a BiPAP rental for 99 months.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
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 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 
requested physician's services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammaplex. 
 
You asked the Plan to pre-approve Gammaplex. You say that the requested Gammaplex is medically necessary. 
The Plan denied your request. The Plan says the requested Gammaplex is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Gammaplex. Our reviewer says that the 
requested Gammaplex is not medically necessary. Our physician reviewer found the enrollee is with a 
diagnosis of Neuromyelitis optica. Neuromyelitis optica is a very rare severe idiopathic immune-mediated 
demyelinating and axonal damaging disease that predominantly affects the optic nerves and spinal cord. The 
enrollee was treated in the hospital with IV steroids in June, 2020. Her symptoms started to improve, but then 
started to return. Since her symptoms are getting worse, a trial of IVIG has been recommended. Other potential 
alternative preventive treatment options are being considered. 
 
The requested use of Gammaplex is not FDA-approved for the enrollee's diagnosis. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammaplex have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammaplex.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional transforaminal epidural injections. 
 
You asked the Plan to pre-approve 2 additional transforaminal epidural injections. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says Medicare will only cover 2 
transforaminal epidural injections on the same day. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare will only cover 2 transforaminal epidural injections on the 
same day. The request was for 4 transforminal epidural injections. The Plan approved the two allotted 
injections. Based on this information, we decided that Medicare rules for coverage of 2 additional 
transforaminal epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-
approve 2 additional transforaminal epidural injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve von Willebrand genetic testing. 
 
You asked the Plan to pre-approve the requested services. You say that the lab work is to better characterize the 
subtype of von Willebrand disease. The Plan denied your request. The Plan says the results of the testing will 
not directly impact treatment or management. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. In this case, there were insufficient records to show that the testing 
results would be used to determine a specific treatment strategy or diagnosis. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pre-approve von Willebrand genetic testing.
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. The Plan denied your request. The Plan says the 
enrollee does not require daily physician visits or complex nursing care that isn't available at other levels of 
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 found to have enterococcus sepsis, requiring IV antibiotics. The enrollee 
is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH 
that the enrollee requires that are not available at the health care setting being offered by the health plan. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of 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 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.