Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network tertiary 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 medically necessary care is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 tertiary provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental extraction (D7210) on tooth # 21. 
 
You asked the Plan to pre-approve a dental extraction (D7210) on tooth # 21. You say that the requested dental 
extraction (D7210) on tooth # 21 is medically necessary. The Plan denied your request. The Plan says the 
requested dental extraction (D7210) on tooth # 21 is not medically necessary and the documents currently 
qualify tooth # 21 removal with a less severe extraction code. 
 
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. The Plan covers a dental 
extraction (D7210) on tooth # 21 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 a dental extraction (D7210) on tooth # 
21. Our reviewer says that the requested dental extraction (D7210) on tooth # 21 is not medically necessary. 
Our physician reviewer found a review of the enrollee's dental record and radiographs indicate that tooth #21 
does not require a surgical extraction. There appears to be significant bone loss and adequate supragingival 
tooth structure to allow removal via elevation and/or forceps removal (D7140).  
 
The documentation does not support the need for a surgical extraction (D7210) of tooth #21. The amount of 
bone loss and adequate supragingival tooth structure would appear to allow a less involved extraction 
procedure. 
 
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 a dental extraction (D7210) on tooth # 21 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a dental extraction (D7210) on tooth # 21.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system. 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF 
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
system is 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 CardioMEMS HF system. Our 
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer 
found the enrollee is with a history of kidney disease, diabetes, long QT with defibrillator placement, coronary 
disease and NYSHA Class III congestive heart failure with reduced LV ejection fraction (LVEF 30%) 
requiring hospitalization. 
 
In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated 
in only one trial to help reduce hospital readmission compared to standard medical therapy.  Moreover, 
concerns have been raised about potential bias in this trial calling into question the results.  Therefore, the 
efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not 
recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not met 
since the device should still be considered experimental or investigational. 
 
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 CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic bridge on tooth #10 (D6245) and 
porcelain/ceramic crowns for teeth #9 and 11 (D6740). 
 
You asked the Plan to pre-approve a porcelain/ceramic bridge on tooth #10 and porcelain/ceramic crowns for 
teeth #9 and 11. 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 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 
porcelain/ceramic bridge on tooth #10 (D6245) and porcelain/ceramic crowns for teeth #9 and 11 (D6740).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve a PET scan. You say that the requested PET scan is medically necessary. 
The Plan denied your request. The Plan says the requested PET scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the 
requested PET scan is not medically necessary. Our physician reviewer found the enrollee is with lung abscess 
and empyema. The enrollee has nodular opacities that are not likely malignant and are probably scars. The 
enrollee does not meet criteria for the requested PET scan in this case as the enrollee has a low suspicion for 
malignancy. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Supartz FX injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria was not 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 the injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
tried and failed to required drugs. The documentation does not support that Orthovisc and Monovisc would 
likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Supartz FX injection for the enrollee.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of 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 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 medical records provided the complexity of the enrollees nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but 
based on the medical records provided the enrollee does not require treatment in 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from therapy 
and wound care in the SNF setting due to limited gait tolerance and poor safety awareness. The Plan denied 
your request. The Plan says daily skilled services are not medically necessary. 
 
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 SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 96 year old male 
admitted on 9/2 after being found unresponsive. He was found to be in atrial fibrillation with rhabdomyolysis 
and a lumbosacral pressure ulcer. From a nursing perspective, the beneficiary received oral medications. The 
beneficiary had stable vital signs. He had wound care to multiple wounds. Regarding rehabilitation services, 
the beneficiary received PT in the acute hospital. The beneficiary was at a supervision to contact guard assist 
level with functional mobility including gait to 300 feet with a rolling walker.   
 
There are identifiable skilled nursing and skilled therapy needs; however, daily skilled services are not 
required. This beneficiary does 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan 500mg/50ml vial for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria was not followed. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not support that Remicade OR Inflectra; AND Simponia Aria have been tried and failed. The documentation 
does not support that the plan's drug would likely be less effective, and/or would likely have adverse effects for 
the enrollee in this case. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan 500mg/50ml vial for the enrollee.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 medical records do not indicate that there are significant, or complex 
medical/nursing issues that require an IRF level of care. The medical records show you are at minimal 
assistance for functional transfers and need maximum assist for lower body daily activities. The medical 
records do not show an IRF level of care is warranted. Medicare coverage criteria are not met. 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee was admitted to 
acute care with congestive heart failure, difficulty breathing, and obstructive sleep apnea. The enrollee is status 
post medical management. Now, hemodynamics are stabilizing, but she remains profoundly weak and fatigued. 
She is maximum assist for care overall, with poor endurance.  
 
Records do not indicate that there are significant, or complex medical/nursing issues that could not be 
addressed at a lesser level of care.  Ongoing pain medication and other medication management, skin and 
oxygen care, and daily therapy can be provided at a lesser level of care.  In this case, the member is mostly 
maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of 
therapy may be more appropriate.  It is not clear the member would be able to fully benefit and/or participate in 
an IRF level of 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve the continued PT sessions. You say that you feel that you are still making 
progress but also that the sessions provide beneficial pain relief. The Plan denied your request. The Plan says 
since you have not made sustain improvement, continued PT is not deemed 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 continued PT sessions. 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 enrollee is a female with cerebral palsy with left 
sided hemiplegia She had a left hip osteotomy with chronic pain. Recent x-ray reveals right hip arthritis. She 
complains of left hip pain with sitting, lying, prolonged walking & standing. She is receiving PT for pain 
management of shoulder and hip. The enrollee has not demonstrated any significant improvement functionally 
per review of records. 
 
For pain involving the hip, physical therapy (PT) is generally accepted as specific and effective therapy.  Goals 
include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to 
transition towards a home program. In this case, there is no indication prior PT has served to provide sustained, 
significant improvement in pain and/or function and there is no indication residual deficits could not be 
addressed via a home exercise program. Therefore, this request is deemed not 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 continued PT sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional physical therapy (PT) sessions.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 that you require varied levels of assistance (minimal to maximum) for functional 
mobility, transfers and daily activities. The medical records do not show an IRF level of care is appropriate. 
The medical records do not indicate the enrollee would be able to fully benefit and/or participate in an IRF 
level of care. Medicare coverage criteria are not met. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria for SNF services are not 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 services. Our reviewer says that daily skilled services are not necessary. Our physician 
reviewer found based on the medical records provided, the enrollee does not require daily skilled nursing or 
daily skilled therapy services provided at an inpatient SNF level of 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 SNF 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing 
facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve a second opinion. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to 
seek out-of-network care. The Plan says that there are equally qualified in-network providers available to you 
that can provide the care you need. 
 
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 second opinion to be provided by an out of network (OON) provider.