Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7210) of tooth #29 and an immediate 
maxillary denture (D5130). 
 
You asked the Plan to pre-approve the extraction and immediate maxillary denture. The Plan denied your 
request. The Plan says the x-rays provided were not labeled properly. 
 
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 extraction 
and immediate maxillary denture when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the extraction and immediate maxillary 
denture. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation provided for the review is insufficient. Our reviewer also found that the enrollee's dental record 
does not contain any information pertaining to the need for the service, and the radiographs provided are not of 
diagnostic quality. 
 
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 extraction and immediate maxillary denture have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an extraction (D7210) of tooth #29 and an immediate 
maxillary denture (D5130).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical treatment/spinal cord stimulator (SCS) 
implantation (63650 and 63685). 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that it is your medical opinoun that the 
treatment sought is clinically supported and medically necessary based on the enrollee's complaints and 
objective evidence documents on the physical examination. The Plan denied your request. The Plan says under 
Medicare guidelines, this request is not medically necessary because the diagnostic indications required for 
approval were not documented in the medical history. 
 
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 spinal cord stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic neck pain. She is taking Percocet, Lyrica, Flexeril, 
Diclofenac, Mobic and Lidoderm patches. She had a cervical SCS trial and the request is for permanent 
implant. She does not have an evidence based indication for a SCS. The request is not medically reasonable or 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electrical treatment/spinal cord stimulator (SCS) implantation (63650 and 63685).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient hospital services. 
 
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 continued 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 continued services are not medically necessary. Our physician reviewer found the submittd records show 
that you were treated with conservative care for cellulitis. The records show that you are now medically stable 
and were not found to have a persistently elevated white blood cell count to justify ongoing inpatient care. The 
continued inpatient 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 continued inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay forthe continuous glucose monitor and supplies provided on June 8, 2020.You asked the Plan to pay forthe continuous glucose monitor (CGM) and supplies (K0533). You say that the Plan should pay this claim.The Plan denied your request. The Plan says that the diagnosis code does not substantiate the service.The Plan must follow Medicare rules. Medicare rules say that for any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.We looked at the file and Medicare rules. The enrollee meets the criteria and the modifier has been corrected. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor and supplies (K0533) have been met.Therefore, we decided that the Plan has to pay forthe continuous glucose monitor and supplies provided on June 8, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the member is danger to 
himself, his family, and his community. The Plan denied your request. The Plan says that that the enrollee can 
be treated in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are medically reasonable and necessary for the 
enrollee in this case. This enrollee does require inpatient mental health treatment beyond the dates in question 
as although he was not a danger to himself or others this patient was quite delusional. It does appear that active 
treatment is taking place. It appears that the services for the dates in question were reasonably expected or 
medically necessary to improve the patient's condition or for the purpose of diagnosis. It appears that the 
services were supervised and evaluated by a physician. Our physician reviewer found that the enrollee's 
condition meets criteria for coverage of inpatient psychiatric hospital 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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric hospital services for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria 
 
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 Prolia. Our reviewer says that the 
documentation does not support a history of an osteoporotic fracture or previous treatment, contraindication, or 
intolerance to both an oral bisphosphonate drug and zoledronic acid. Our physician reviewer found step 
therapy, as outlined by the plan, requires these be trialed first or a documentation of a contraindication.  
Without the support of the documentation, step criteria is 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental crowns provided on January 29, 2020.You asked the Plan to pay forthe dental crowns. You say that you were advised the service is covered.The Plan denied your request. The Plan says the service is not a covered benefit.Medicare generally does not cover dental services. The Plan follows the same rule.At the time the services were provided, you were not enrolled in the Plan's supplemental dental benefit. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe dental crownsprovided on January 29, 2020.
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 cannot be adequately cared 
for in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says the 
enrollee's medical needs are being met in the current acute setting. 
 
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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital with COVID-19 pneumonia, 
and acute respiratory failure. Recent notes show that she is recovering based on improved symptoms and x-ray 
findings. However, additional short-term acute care services are needed, which is likely to take less than 25 
additional days, and can safely be completed at the current facility. She does not require services at the LTACH 
that are not already available at the current facility. Therefore, this request for LTACH services is considered 
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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe cardiology office visit and EKG you had on March 12, 2020 and the echocardiogram you had on March 18, 2020.You asked the Plan to waive the copayments forthe cardiology office visit, the EKG, and the echocardiogram. You say that you were told you would only have a $20 copaymentThe Plan denied your request. The Plan says you were charged these copayments correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for specialist visits, a $20 copayment for EKGs, and a $100 copayment for radiologic diagnostic services. You have been asked to pay a $30 copayment for the cardiology office visit, a $20 copayment for the EKG, and a $100 copayment for the echocardiogram, for a total of $150. The cardiology office visit falls within the specialist visits benefit category.  Your Evidence of Coverage also states that you pay a $20 copayment for EKs.  Finally, your Evidence of Coverage states that you pay a $100 copayment for radiologic diagnostic tests.  The echocardiogram you had is a radiologic diagnostic test. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments forthe cardiology office visit and EKG you had on March 12, 2020 and the echocardiogram you had on March 18, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare criteria for SNF 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 pre-approve the SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee has 
stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing 
and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at 
a lower level of care. Although further rehab services would be appropriate to improve function, as a practical 
matter, the daily skilled services can be provided at a lower level of care than a skilled nursing facility. The 
enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. She 
 
 
is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or 
near her baseline and she can receive services at a lower 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc 850. 
 
You asked the Plan to pre-approve Genvisc 850 (J7320). You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says the enrollee has not first tried and had an intolerance to 
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 Genvisc 850 (J7320). Our reviewer 
says that the drug is not medically necessary. Our physician reviewer found the enrollee has not trialed 
viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires 
these be trialed first. The documentation does not outline contraindications or reasons these medications were 
not considered. Without the support of the documentation, Genvisc 850 is not approved as step criteria is 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 Genvisc 850 (J7320) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Genvisc 850.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for coverage of an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's needs can be met at a lower 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional ostomy supplies. 
 
You asked the Plan to pre-approve the requested supplies. You say that you need 120 units every 6 months. 
The Plan denied your request. The Plan says that the records do not provide documentation to support a greater 
quantity of supplies. 
 
The Plan follows Medicare rules. Medicare rules say that the explanation for use of a greater quantity of 
supplies than the amounts listed must be clearly documented in the beneficiary's medical record.  
 
The documentation shows that 60 units of a convex insert ostomy accessory (CPT A5093) were requested. 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 supplies. Our physician 
reviewer found that you have an ileostomy. Ileostomies are often high output and require increased number 
supplies over colostomies. The records do not show that you have requested an excessive amount of supplies. 
Therefore, the requested supplies are medically reasonable and 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 requested supplies have been met. Therefore, we decided that the Plan has 
to pre-approve additional ostomy supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat facet joint injections. 
 
You asked the Plan to pre-approve the repeat injections. You say that this should be covered as the treatment 
reduced the enrollee's pain enough to help her increase function. The Plan denied your request. The Plan says 
the enrollee did not obtain sufficient relief from the first injection to warrant another. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint pain is diagnosed by dual injections (a 
series of two sessions). The second injection is covered when the first produced at least 50% pain relief.  
 
In this case, the file shows that only 25% pain relief was provided by the first injection. As such, the criteria for 
a confirmatory injection have not been met. Therefore, we decided that the Plan does not have to pre-approve 
repeat facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveIRFadmission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says based on Medicare guidelines, the Inpatient Rehabilitation Facility (IRF) services you and/or your provider are requesting do not meet the requirements for approval.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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgery of the cervical and thoracic spine. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does 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 this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in anIRF.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-approveIRFadmission and services.