Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that an inpatient hospital level of care 
is medically necessary and has been requested by the doctor because the enrollee's pain isn't under control. The 
Plan denied your request. The Plan says the enrollee's fall did not result in any injury that requires inpatient 
treatment. The Plan says that observation level care is appropriate and has been approved. 
 
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.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee is an 87-year-old female who had fallen presented to the 
emergency department with knee and hip pain. X-rays showed no acute abnormality. She has a history of 
frequent falls regardless of her having 24 hour aides. She did not report dizziness, palpitations, or shortness of 
breath. She was treated with Tylenol and a Lidoderm patch and her vitals were stable. No pain levels were 
noted in the documentation. She was noted to not be in any acute distress. She was diagnosed with ecchymoses 
and deconditioning as well as frequent falls. She was admitted to the hospital. Considering the documentation 
provided, at the time of admission, there was no indication that the enrollee's pain was not controlled 
reasonably and there was no medical indication which required acute care services in an inpatient setting for at 
least 2 midnights. Placement decisions and basic pain control could have been performed in observation status, 
based on the documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (CPT Code 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer device is experimental. More research is needed to show safety and efficacy. 
 
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869) 
and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression 
or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fentanyl 25mcg/hr patches. 
 
You asked the Plan to pre-approve the fentanyl patches. You say that this is necessary. The Plan denied your 
request. The Plan says this self-administered dermal patch is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve fentanyl 25mcg/hr patches.  
 
Benefits for the fentanyl patches may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy on tooth #9 (D3310) and core 
buildup on tooth #9 (D2950). 
 
You asked the Plan to pre-approve endodontic therapy on tooth #9 and core buildup on tooth #9. You say that 
the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
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 
endodontic therapy on tooth #9 (D3310) and core buildup on tooth #9 (D2950).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71260). 
 
You asked the Plan to pre-approve a CT scan of the chest. 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. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the chest. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found you have a very low and 
stable prostate-specific antigen (PSA) at less than 0.01 ng/ml and no sign of metastatic disease or recurrence 
based on physical exam and prior imaging of 2019. The NCCN guidelines for prostate cancer, Version 2.2020 
do not advocate CT of the chest for surveillance in patients with a history of prostate cancer treated in 2015 
even on androgen deprivation therapy (ADT). In addition the prior glottic cancer was treated with definitive 
radiation therapy per the records in 1997 and there are no symptoms or physical findings to suggest recurrence 
or metastatic disease to justify CT of the chest on that 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 a CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the chest (71260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve immediate denture - mandibular (D5140), immediate 
denture - maxillary (D5130) and panoramic radiographic image (D0330). 
 
You asked the Plan to pre-approve the dental services. You say that the dentures received made your gums 
bleed and the office made you wait a week to schedule an appointment. You state you have been in pain ever 
since and cannot eat. The Plan denied your request. The Plan says you exhausted your benefit frequency limit. 
 
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. 
 
Review of the file shows that you received dentures on February 27, 2020 and a panoramic radiographic image 
was utilized on January 23, 2020. Your EOC states, "panoramic x-ray film(s) (One (1) procedure every three 
(3) years) and complete dentures (upper and lower) (One upper complete and one lower complete denture 
every five (5) years, including routine post-delivery care) or Partial dentures (upper and lower) (One upper 
and/or one lower partial denture every five years, including routine post-delivery care)." Therefore, we decided 
that the Plan does not have to pre-approve immediate denture - mandibular (D5140), immediate denture - 
maxillary (D5130) and panoramic radiographic image (D0330).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from care in the IRF to allow you 
to fully recover. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met in 
this case. 
 
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 is a 93 year old female with a past medical history of hypertension, prior 
pulmonary embolism and dementia who presented to the acute hospital on 09/20/2020 from a skilled nursing 
facility with hypotension. She was treated in the hospital with intravenous fluids for the low blood pressure as 
well as antibiotics and anti-fungal medication for a urinary tract infection. She is weak and deconditioned and 
is working with physical and occupational therapy. She is requiring maximum assistance for mobility, transfers 
and activities of daily living. She has recently been found to have a deep vein thrombosis in the left internal 
jugular vein. Transfer to an acute inpatient rehabilitation facility is requested.  
 
Based on the medical records provided, the complexity of the patient's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The patient does require physical therapy and occupational therapy services, but the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omega-3 Ethyl Esters 1gm capsule. 
 
You asked the Plan to pre-approve Omega-3 Ethyl Esters 1gm capsule. You say that the medication is 
necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not 
include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omega-3 Ethyl Esters 1gm 
capsule.  
 
Benefits for Omega-3 Ethyl Esters 1gm capsule may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) home health PT visits. 
 
You asked the Plan to pre-approve home health PT visits. You say that you will not progress and get better if 
you do not have the thirteen (13) therapy visits. You state you are recovering from a stroke. The Plan denied 
your request. The Plan says the additional visits are not 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 home health PT visits. Our physician 
reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for 
your condition. You have had extensive therapy for this condition and it appears that you no longer require the 
unique skills of a professional therapist to safely and effectively provide treatment for the remaining 8 home 
health PT visits. Services do not only need to be safely and effectively performed by a therapist, or under the 
supervision of a therapist. You should be able to transition to a  home exercise program with the already 
authorized therapy and the specialized skill, knowledge and judgment of a qualified therapist is not required to 
establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight (8) home health PT visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs would be best met in the IRF 
setting. The Plan denied your request. The Plan says the enrollee is not strong enough to participate in three 
hours of daily therapy. 
 
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 is an 82-year-old male with a past medical history of chronic obstructive 
pulmonary disease, arthritis and skin cancer who presented to the acute hospital on 09/23/2020 from a skilled 
nursing facility with a fall and confusion. The enrollee's diagnoses included systemic inflammatory response 
syndrome, acute kidney injury and lower extremity cellulitis. He was also treated in the hospital for 
Clostridium Difficile colitis with vancomycin and Flagyl. He is weak and deconditioned and is working with 
physical and occupational therapy. He is walking 3 feet with a walker with contact guard assistance and is 
minimum assist for transfers and activities of daily living. He is medically stable for discharge. Transfer to an 
acute inpatient rehabilitation facility is requested. 
 
Based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs 
do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
patient does require physical therapy and occupational therapy services; however, the patient does not require 
an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this procedure would be beneficial. 
The Plan denied your request. The Plan says the requested surgery is considered experimental at this time. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy.  
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee does not have medical needs that must be met by an out-of-
network doctor. The Plan states the service will be approved as soon as the enrollee finds an in-network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. 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 out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for nuclear imaging study with CT imaging, 
skull base to mid thigh with 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 similar or equivalent care can be received 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 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 for nuclear imaging study with CT imaging, skull base to mid thigh with an out-of-network provider.
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 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 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
abdominal pain, nausea and vomiting. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do 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. 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. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 2, 2019.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says care receive from a non-network provider will not be covered

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 July 2, 2019.