Persius/hicric huggingface dataset:
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 a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says a LTACH admission is not medically 
necessary for the enrollee. 
 
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 that the enrollee presented to the emergency room with abdominal pain and rectal 
bleeding. She was evaluated and admitted for acute diverticulitis. She was treated with IV antibiotics and 
underwent placement of a percutaneous drain due to abscess formation. She will require nutritional support and 
physical/occupational therapy services. The enrollee when considered medically stable, may be an appropriate 
candidate for admission to a less intense level of care such as a skilled nursing facility. The review has 
determined that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she is currently receiving 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 health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric admission. You asked the Plan to pre-approve inpatient psychiatric admission. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. 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 inpatient psychiatric admission. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of August 18, 2020 forward as the enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations, delusions and was cooperative/compliant with treatment while not showing any threats to the safety of herself or others. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Botox injection (J0585). 
 
You asked the Plan to pre-approve a Botox injection. You say that the medication is necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 a Botox injection. Our reviewer says 
that the medication is not medically necessary. Our physician reviewer found Botox was order for the treatment 
of your gastroparesis. Review of compendia does not support the use of Botox has been supported by studies 
for this condition. Without the support of the documentation, medical necessity cannot be determined. 
 
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 Botox injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Botox injection (J0585).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) skilled nursing visits (CPT Code G0299). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records do not support the need for a skilled nurse to make more visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 nine (9) skilled nursing visits (direct skilled nursing services of a registered nurse (RN) in the home 
health or hospice setting, each 15 minutes (CPT Code G0299) are not medically necessary. The records do not 
support that skilled nursing services are required to effectively provide treatment, care, and/or services in order 
to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's 
condition and/or prevent deterioration. The patient has no complex wound and her chronic medical conditions 
are stable and do not require the ongoing skills of a professional nurse. 
 
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 nine (9) skilled nursing visits (CPT Code G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair. 
 
You asked the Plan to pre-approve a group 2 power wheelchair. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device or a push-rim activated 
power assist is covered when specific criteria is 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 a group 2 power wheelchair. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the enrollee meets the coverage criteria. There is no 
documentation in the provided records that the enrollee has a mobility limitation that significantly impairs his 
ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, 
feeding, dressing, grooming, and bathing in customary locations in the home. There is no documentation in the 
provided records that the enrollee's mobility limitation cannot be sufficiently and safely resolved by the use of 
an appropriately fitted cane or walker or an optimally-configured manual wheelchair. 
 
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 group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 2 power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast cancer gene analysis (81162). 
 
You asked the Plan to pre-approve the analysis. You say that you would like reconsideration because the 
member has a family history of malignant neoplasm of the ovary. The Plan denied your request. The Plan says 
the member does not have a diagnosis or symptoms of breast cancer. 
 
 
The Plan follows Medicare rules. Medicare rules say that NGS as a diagnostic laboratory test may be 
considered medically necessary when the patient has somatic or germline cancer. 
 
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 analysis. Our reviewer says that the 
member does meet Medicare coverage criteria for this service. Our physician reviewer found the member does 
not have a personal history of cancer. 
 
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 analysis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve breast cancer gene analysis (81162).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services 
with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter, you do not require the necessary 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L3960, L2830, L2820, L2385, L2397, L1851, 
L0650, L3170, L1971, L3916) provided on April 6, 2020. 
 
You asked the Plan to pay for orthotics. You say that you did not order these devices. The Plan denied your 
request. The Plan says the examination that led to the prescription of these devices did not meet telehealth 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for orthotics (L3960, L2830, 
L2820, L2385, L2397, L1851, L0650, L3170, L1971, L3916) provided on April 6, 2020.  
 
 
 
Your complaint about being sent these items without order them 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).You asked the Plan to pre-approve a core buildup. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's contractual dental policy.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 service is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).You asked the Plan to pre-approve the maxillary partial denture. The Plan denied your request. The Plan says a partial denture is not medically necessary.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. The Plan covers the maxillary partial denture when the services are medically necessary and reasonable. 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 maxillary partial denture. Our reviewer says that the service is not medically necessary. Our physician reviewer found eight natural or prosthetic teeth in occlusion (four maxillary and four mandibular teeth in functional contact with each other) are generally considered adequate for functional purposes. One missing maxillary anterior tooth or two missing mandibular anterior teeth may be considered a problem that warrants a prosthetic replacement. Our physician reviewer found that in this instance, with use of the approved partial lower denture, there would be an adequate number of teeth in contact to provide occlusion. Our reviewer also found that the upper maxillary partial denture (D5213) would not be considered medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the maxillary partial denture have not been met.Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build-up including any pins when required (D2950).You asked the Plan to pre-approve the dental service. You say that you are missing your first molars and is not able to chew properly.The Plan denied your request. The Plan says this service is not listed as 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 core build-up including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 3.You asked the Plan to pre-approve the dental services. You say that the enrollee has a failing restoration with disto lingual cusp possibly weak. You say there is a fracture line noted on the lingual aspect of the tooth. You also say that caries would be controlled with core build up and crown.The Plan denied your request. The Plan says core build up is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, core build up is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) and a crown (D2740) for tooth # 27.You asked the Plan to pre-approve the dental services. You say that there is recurrent decay around the crown on tooth # 27. You say that the cervical recurrent decay previously attempted to be restored with a MF composite in 2016. You say there continues to be a problem with this tooth undermining margins and crown adaption. You also say that in order to save the tooth, a new crown and build up are needed.The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says 1 crown, per tooth, per 60 months, per patient is covered. The Plan also says that the benefit for crowns has been exhausted.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, core build up is not among those covered under this benefit. Although crowns are a covered service, the benefit limit of 1 per tooth, per 60 months has been exhausted. The record shows that the Plan paid for a crown for tooth # 27 that you received on April 18, 2017.Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) and a crown (D2740) for tooth # 27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT image capture with field of view of one full dental arch (D0382) and biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery (D3431).You asked the Plan to pre-approve the cone beam CT image capture and biologic materials to aid in soft and osseous tissue regeneration. You say that your regular dentist referred you to an endodontist.The Plan denied your request. The Plan says these services are not covered under your benefit 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 a cone beam CT image capture with field of view of one full dental arch (D0382) and biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery (D3431).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing 
provided to the enrollee on January 7, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health 
of the patient are not a benefit. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that the molecular genetic hereditary predictive screening testing at 
issue was medically reasonable and necessary for the enrollee in this case. The case file contains an unsigned 
Cardiology Genetics Test Requisition. There are no clinical records in the case file. There is no documentation 
supporting an established relationship between the enrollee and the anesthesiologist who ordered the predictive 
screening testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on May 28, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you need the hearing aids to maintain your normal 
lifestyle. The Plan denied your request. The Plan says that this is excluded. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aids 
provided on May 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 23, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 
laboratory 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 laboratory services provided on March 23, 2020.