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

 
We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare will not pay for current skilled nursing services after October 7, 2020. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued admission to a skilled nursing facility.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 21, 2020, 
to March 28, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 21, 2020, to March 28, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do 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 you were admitted to the acute hospital with urinary retention status post placement of a Foley 
catheter. You received continued care for an unstageable sacral decubitus ulcer. Passive range of motion of 
your lower extremities is limited due to pain. There are no identifiable skilled therapy service needs. Although 
there are identifiable skilled nursing service needs, you do not require skilled therapy or nursing services on a 
daily 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) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is 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 considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be experiencing pulmonary improvement, however, additional 
short-term acute care services (less than 25 days) is needed for additional weaning. The patient does not require 
any services at the LTACH that are not already available at the current setting. There are no services at the 
LTACH that the patient requires that are not already available and covered at the current setting. Therefore, this 
request for LTACH services will be considered not medically necessary. Continued care in the current setting 
for the short term appears most appropriate for weaning. Transfer to a lower level of care may be considered 
when more stable and when prognosis more clear. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a interspinous and/or interlaminar device. 
 
You asked the Plan to pre-approve a interspinous and/or interlaminar device. 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 a interspinous and/or interlaminar 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have spinal stenosis and neurogenic claudication. You 
have failed conservative therapy. The evidence in the peer-reviewed medical literature does not clearly support 
that interspinous distraction devices are safe and effective in the treatment of lumbar spinal stenosis. The 
effectiveness, side effects, recovery time, and long-term outcomes have not been well established and this 
device is not part of established clinical practice guidelines. 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 a interspinous and/or interlaminar device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a interspinous and/or interlaminar device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of back pain. 
The Intracept procedure is considered experimental in nature, as more research is needed to show the safety 
and efficacy for back pain treatment. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultralight wheelchair and accessories. 
 
You asked the Plan to pay for the ultralight wheelchair and accessories. You say that you would like 
reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says the 
request is not medically necessary because there is no indication that you are unable to use a standard manual 
wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultralight wheelchair and accessories have not been met. Specifically, the record does not 
include medical records to verify if the requested equipment is medically necessary. Of note, the record 
indicates that the Plan requested clinical notes and none were received. Therefore, we decided that the Plan 
does not have to pay for an ultralight wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the out of network cardiology services. The Plan denied your request. The 
Plan says there are providers within the health plan network that can supply the services needed. 
 
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 
cardiology services to be provided by an out of network (OON) provider.
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 there are no 
identifiable skilled needs. 
 
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 received oral medications, had stable vital signs, and her 
lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee 
had no therapy notes to document the need for skilled services. The enrollee 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: 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 physician supervision, or a multidisciplinary team for care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that you were admitted to the acute hospital for altered mental status. Your medications have been adjusted, 
and your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. The medical record supports a need for physical and occupational 
therapy, but it does not support a need for an intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is 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 considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be improving and responding to treatment, however, additional 
short-term acute care services (less than 25 days) is needed based on the recent records. The patient does not 
require any services at the LTACH that are not already available at the current setting. There are no services at 
the LTACH that the patient requires that are not already available and covered at the current setting. Therefore, 
this request for LTACH services will be considered not medically necessary. Continued care in the current 
setting for the short term 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor treatment field therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee cannot tolerate the device an average of 18 hours per day. 
 
The Plan follows Medicare rules. Medicare rules say that tumor treatment field therapy is only covered under 
certain medical indications.  
 
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 services. Our physician 
reviewer found that the coverage criteria for the requested services have not been met. The documentation does 
not show that the treatment is being initiated within 7 weeks from the last dose of concomitant chemotherapy 
or radiotherapy. The enrollee does not have a KPS score of at least 70. There is no documentation that the 
enrollee can use the treatment for an average of 18 hours per day. Therefore, the requested treatment is not 
medically reasonable and 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve tumor treatment field therapy.
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 the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says no medical need is shown as to why this needs to be done out-of-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 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 
a referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sensor; invasive (e.g., subcutaneous), disposable, for use 
with interstitial CGM system (A9276), transmitter; external, for use with interstitial CGM system (A9277) and 
receiver (monitor); external, for use with interstitial CGM system (A9278). 
 
You asked the Plan to pre-approve the services. You say that the DME is necessary. The Plan denied your 
request. The Plan says "A codes" are never covered by Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. These codes are not covered by 
Medicare, because they are not for a "therapeutic" CGM machine. Medicare only covers "therapeutic" CGM 
machines, when the Medicare criteria are met. Therefore, we decided that the Plan does not have to pre-
approve sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial CGM system (A9276), 
transmitter; external, for use with interstitial CGM system (A9277) and receiver (monitor); external, for use 
with interstitial CGM system (A9278).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Heritable Disorders of Connective Tissue (HDCT) 
genetic testing by the provider. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has multiple complaints, 
including pain. Heritable Disorders of Connective Tissue (HDCT) genetic testing has not been shown to be the 
standard of care for the enrollee's condition. The documentation in the case file does not support that the 
requested HDCT testing would impact the health of the enrollee in this case. Testing which has no proven 
relation to the management of a medical diagnosis of disease for the health of an enrollee is not a covered 
Medicare benefit. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Heritable Disorders of Connective Tissue (HDCT) genetic testing by the provider.  
 
Local Coverage Article (LCA) A57526 referenced by the Plan is not binding for the state of Maryland where 
the testing is performed and was not used in this determination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical extractions. 
 
You asked the Plan to pre-approve the surgical extractions. The Plan denied your request. The Plan says the 
documentation submitted does not support the code requested. 
 
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 surgical 
extractions 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 surgical extractions. Our reviewer 
says that the criteria for coverage has not been met. Our physician reviewer found as there is significant bone 
loss around #21 and #29, and a substantial amount of structure remaining on #22 and #28, it would not be 
anticipated that surgical extractions would be required to remove these teeth. 
 
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 surgical extractions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the surgical extractions.