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 you disagree with the denial. The Plan 
denied your request. The Plan says the requested LTACH care 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on July 20, 2020 with cough, fever, and shortness of breath. She was treated for 
COVID-19 pneumonia and respiratory failure. She does not require services at the long-term acute care 
hospital (LTACH) that are not available at the acute care hospital where she is currently receiving care. She 
does not require services at the LTACH that are not available at the health care setting being offered by the 
health plan. The LTACH services are 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 occupational therapy visits. 
 
You asked the Plan to pre-approve the 10 occupational therapy visits. You say that the occupational therapy 
visits being requested are medically necessary. The Plan denied your request. The Plan says additional 
occupation therapy is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 10 occupational therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as 
specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy but is noted to 
have a learning disability, severe impairment with 2 step commands, and aides to provide necessary care on her 
long term care unit. Her deficits, current functional level, and records do not indicate she requires the unique 
skills of a professional therapist to safely and effectively provide treatment. Services do not need to safely and 
effectively be performed only by a therapist, or under the supervision of a therapist. The requested services are 
not  part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is 
not required to establish, design and/or deliver a program to maintain the patient's 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 the 10 occupational therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 occupational therapy visits.
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 the enrollee needs to be transferred to an 
LTACH because her condition has stabilized but she still requires a multi-disciplinary approach for an 
extended period of time. The Plan denied your request. The Plan says there is no advantage in moving the 
enrollee from the current acute care hospital to an LTACH. 
 
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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
COPD.  The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has been 
weaned from the ventilator to a tracheotomy collar.  There is no evidence that the enrollee requires services that 
are not currently available. There is no advantage in transferring the enrollee to the LTACH.  The enrollee can 
remain at the current ACH until such a time that no acute services are required.  The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nubeqa for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under 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 Nubeqa for the enrollee.  
 
Benefits for this drug 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the right hip. 
 
You asked the Plan to pre-approve an MRI of the right hip. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the right hip. Our reviewer 
says that the documentation does not support that the requested MRI is medically reasonable or necessary. Our 
physician reviewer found the enrollee apparently had pain. The X-rays identified non-acute lumbar 
compression fractures and a non-specific left sacral lucency. It is unclear why an MRI of the right hip has been 
ordered. Therefore, the enrollee does 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 an MRI of the right hip have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the right hip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new lower partial denture. 
 
You asked the Plan to pre-approve the lower partial denture. You say that the dentures that you were given do 
not fit correctly and you want to return them and get new dentures. The Plan denied your request. The Plan 
says this is not covered by your plan. Your prior plan also only covered dentures once every five years. 
 
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, your 2020 dental does not provide 
coverage for dentures. It is noted you received dentures in December 2019 under a different benefit plan, but 
this coverage also only covers dentures once every five years. Therefore, we decided that the Plan does not 
have to pre-approve a new lower partial denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you not meet 
Medicare's coverage criteria. 
 
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 based on the available records, you do not meet CMS criteria for coverage for IRF 
admission. You are currently medically stable after an uncomplicated right total knee arthroplasty (TKA) on 
oral medications for blood pressure and pain and there is no evidence of complex medical issues that require 
monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While you 
may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an 
intensive therapy program with therapy 3 hours per day with frequent physician oversight and an 
interdisciplinary approach to rehabilitation care. An uncomplicated unilateral TKA does not need an IRF 
admission. You do not meet the Medicare coverage criteria for admission to an IRF based on lack of medical 
complexity and current functional status. Your rehab needs can be met in a lower intensity alternate setting 
such as a SNF. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), expandable 
controller (E2377), expandable controller harness (E2313) and electronic connection (E2311). 
 
You asked the Plan to pre-approve power seat elevation system, expandable controller, expandable controller 
harness and electronic connection. You say that you would like reconsideration because these accessories are 
medically necessary. The Plan denied your request. The Plan says there is not a medical need to control these 
power options through the joystick. 
 
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 power seat elevation system, 
expandable controller, expandable controller harness and electronic connection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the seat elevator (E2300) is statutorily non-covered. The expandable controller and harness and 
electronic connection (E2377, E2313 and E2311) do not appear medically necessary as the member has at least 
4/5 bilateral upper extremity strength based on the provided records and this appears to be adequate to control 
the power options using their own switches which are included. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power seat elevation system, expandable controller, expandable controller 
harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power seat elevation system (E2300), expandable controller (E2377), expandable controller harness 
(E2313) and electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like to see this provider because 
your primary care physician referred you. The Plan denied your request. The Plan says there are in-network 
providers available for these services. 
 
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 
specialist services to be provided by an out of network (OON) provider.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your needs for ongoing and additional assistance could be met in a less 
intensive setting. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require 
intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as 
physical and occupational therapy but the documentation does not support that your functional status requires 
or can fully tolerate an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn03. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Orthovisc and Monovisc. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our physician reviewer 
found that the enrollee has bilateral knee osteoarthritis. The Plan requires a trial of Orthovisc and Monovisc 
before they will approve the requested drug. There is no evidence that the enrollee is allergic to or intolerant of 
Orthovisc or Monovisc. There is no evidence that the enrollee has tried and not responded to Orthovisc or 
Monovisc. There is no documentation as to why the required drugs would not be expected to be safe and 
effective for the enrollee. Therefore, the requested Gelsyn-3 is not shown to be currently medically necessary 
and reasonable. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn03 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown (D2759) and core build up (D2950). 
 
You asked the Plan to pre-approve a dental crown and core build up. You say that you have $750 available 
under the dental plan. The Plan denied your request. The Plan says these 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 a 
dental crown (D2759) and core build up (D2950).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Durolane injection. 
 
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee has not 
failed at least three months of conservative therapy. 
 
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 Durolane. Our physician reviewer 
found that there was no documentation provided that the enrollee has tried conservative, non-pharmacologic 
treatments, such as education, strengthening and range of motion exercises. There was no documentation 
provided that the enrollee has had previous treatment, contraindication or intolerance to simple analgesic 
therapy. Based on the rules and records provided, the enrollee does not meet the indications for coverage. 
Therefore, the requested drug, Durolane, is not medically reasonable and necessary to treat 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Durolane injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary and mandibular dentures. 
 
You asked the Plan to pre-approve dentures. You say that you need these dentures. The Plan denied your 
request. The Plan says the denial of authorization is correct, because the requested dentures are not covered by 
the Plan. 
 
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 
complete maxillary and mandibular dentures.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec. 
 
You asked the Plan to pre-approve Nurtec. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Nurtec.
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 the core buildup. You say that the enrollee needs a core buildup on tooth #8. 
The Plan denied your request. The Plan says this service is 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 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 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 extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that this tooth is broken to its root and is 
protruding. The Plan denied your request. The Plan says you exhausted your benefit. 
 
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. 
 
You exhausted your benefit because you had dental extractions on tooth #20 on March 17, 2020 and for teeth 
$4 and #10 on September 1, 2020. Your EOC states, "Non-surgical or surgical extractions (pulling teeth) 
(Three (3) procedures per calendar year." Therefore, we decided that the Plan does not have to pre-approve 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210).