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 this is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs could be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be gradually improving and is approaching his baseline oxygen 
requirements, but requires additional acute care services of less than 25 days which can safely be performed at 
the current facility. The patient does not requires services at the LTACH that are not already available at the 
current 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 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 pre-approvethe medical services to be provided by an out-of-network provider.You asked the Plan to pre-approvethe medical services. You say that the services are necessary.The Plan denied your request. The Plan says there are in-network providers that can render the 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-approvethe medical services to be provided by an out-of-network 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 it is felt that the enrollee needs to receive ongoing 
therapy in the hospital setting with an intensive program. The Plan denied your request. The Plan says criteria 
for this level of care 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 enrollee is a male with a history including spinal disease with a failed lumbar 
fusion L1-S1 with a pseudoarthrosis who was admitted to the hospital for a planned revision and extension of 
T11-S1. He was discharged home in stable condition with plans for home health rehab services. The most 
recent therapy notes indicate that he is able to ambulate up to 40 feet with a walker. 
 
In this case, the complexity of the patient?s nursing, medical and rehabilitation needs do not require an acute 
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. The member continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation doesn?t 
 
 
support that he would meet criteria for admission to an acute inpatient rehabilitation facility. There is no 
indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status.   
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulation (SCS) trial. 
 
You asked the Plan to pre-approve the SCS trial. You say that the enrollee requires this treatment for his pain. 
The Plan denied your request. The Plan says there is insufficient evidence of prior treatments. SCS is not 
appropriate at this time. 
 
The Plan follows Medicare rules. Medicare rules say that SCS can be considered reasonable and necessary 
when the above listed criteria are met.  
 
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 SCS trial. Our reviewer says that 
the requested SCS trial is not medically necessary at this time. Our physician reviewer found the enrollee has 
chronic low back pain. On MRI, he has multi-level degenerative disc disease and spinal stenosis. He underwent 
Psychological evaluation and was found to be an acceptable candidate for an SCS. He has not had prior back 
surgery. He does not have any evidence-based indication for a SCS. He has not had any intra-thecal opiates. As 
the enrollee has treatment options remaining, the requested procedure is not considered 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 SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulation (SCS) trial.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve azathioprine 50mg tablets. 
 
You asked the Plan to pre-approve the azathioprine tablets. You say that this drug is necessary. The Plan 
denied your request. The Plan says this oral drug 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 azathioprine 50mg tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99214) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria has not been met. 
 
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 
office visits (99214) to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz injections. 
 
You asked the Plan to pre-approve the Supartz injections. You say that the enrollee needs this treatment. The 
Plan denied your request. The Plan says there is no reason provided that a trial of the preferred agents would 
not be effective. 
 
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 Supartz injections. Our reviewer 
says that the requested Supartz is not considered reasonable and necessary based on step therapy rules. Our 
physician reviewer found the Plan requires a trial of drug Orthovisc or Monovisc before they will approve the 
requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation 
provided indicating that the Plan?s required drug(s) would likely be less effective and/or likely have adverse 
effects for 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 the Supartz injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Supartz injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be rendered by an OON provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to continue to see this OON 
provider. The Plan denied your request. The Plan says you do not have OON benefits that allows coverage to 
receive services from an OON provider without a prior authorization, except in urgent or emergent situations. 
The Plan also says that there are participating providers within your area. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve dental 
services to be rendered by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Logisticare mileage (A0170). 
 
You asked the Plan to pre-approve additional Logisticare mileage. You say that the additional mileage is 
needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. 
Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers 48 one-way transportation trips per calendar year when each one-way trip does not 
exceed 50 miles per year. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional Logisticare mileage (A0170).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready 
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily 
basis. You are 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. You do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can 
 
 
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tubal ligation. 
 
You asked the Plan to pre-approve the procedure. You say that this is needed for sterilization. The Plan denied 
your request. The Plan says this is not covered in this clinical circumstance. 
 
The Plan must follow Medicare rules. Medicare rules say that tubal ligation is not covered for purposes of 
sterilization. 
 
This is being specifically requested for sterilization. Based on this information, we decided that Medicare rules 
for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve tubal ligation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection procedure for sacroiliac (SI) joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT 
Code 27096). 
 
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 member has had five (5) SI joint injections last year which exceeds guidelines of 
four (4) injections per year. 
 
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 member has received five (5) sacroiliac joint injections in the past twelve (12) months. 
There is no specific documentation of an increase in the member's level of function or reduction in analgesic 
medication usage.  In addition, the Plan will not cover more than four (4) injections to the SI joint within a 12-
month period. The requested sacroiliac joint injection 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection procedure for sacroiliac (SI) joint, anesthetic/steroid, with image guidance 
(fluoroscopy or CT) including arthrography when performed (CPT Code 27096).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator, rental (CPT Code 
E1392). 
 
You asked the Plan to pre-approve the DME. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. A portable oxygen system is covered 
if the member is mobile within the home and a qualifying blood gas study was done while at rest (awake) or 
during exercise. The member is not mobile within the home and a qualifying blood gas study has not been done 
while at rest or during exercise. Based on information provided, the member's oxygen needs can be met using 
portable oxygen tanks when going outside the home for doctor visits, lab draws. The provider is able to provide 
various sizes of oxygen tanks to meet this purpose. There is a limit to the amount oxygen that can be provided 
from a single tanks and appropriate arrangements will need to be made with your oxygen supplier. Portable 
oxygen concentrator is not necessary unless portable oxygen tanks are not able to provide adequate oxygen 
duration for the member's visits outside the home, or if the tanks are too large to be effectively and safely 
moved together with the patient and the ventilator. 
 
The member has had oxygen since April 25, 2017. The providers last billable month was on April 25, 2020. 
The newly requested portable oxygen concentrator is beyond the original 36-month rental, but within the five-
year reasonable use lifetime. A new 36-month rental period does not start when providing different oxygen 
equipment based on doctor's orders. Therefore, the Plan does not need to make payments beyond the original 
36 month rental period for use of newly requested portable oxygen concentrator. Therefore, we decided that the 
Plan does not have to pre-approve portable oxygen concentrator, rental (CPT Code E1392).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the documentation provided, you do 
not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have 
documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program 
or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical 
matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) with a joint stabilizer (L2385) provided to the enrollee on May 16, 2020.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) with a joint stabilizer (L2385) provided to the enrollee on May 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a water circulating heat pad with pump. 
 
You asked the Plan to pre-approve a water circulating heat pad with pump. You say that this device will help 
with your therapy process. The Plan denied your request. The Plan says that this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a water circulating heat pad with pump will be 
denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a 
water circulating heat pad with pump.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CPT Code 22869 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 remains 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 CPT Code 22869 22870.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in tub. 
 
You asked the Plan to pre-approve a walk-in tub. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a walk-in tub does not serve a medical purpose and is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in tub.