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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because you 
desperately need the assistance of the rehab care because you are falling multiple times a day and require 
medical care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not 
been 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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your 
care 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the lateral branches of S1-
S3. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered for certain 
indications. 
 
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 radiofrequency facet ablation. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has had 2 
diagnostic SI joint blocks which produced 90-100% pain relief. The enrollee has failed conservative therapy. 
The request is considered an experimental/ investigational procedure because of the wide variation in efficacy 
reported in the peer reviewed literature. 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 radiofrequency facet ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation of the lateral branches of S1-S3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea mastectomy sleeve.You asked the Plan to pre-approvethe sleeve. You say that this is medically necessary.The Plan denied your request. The Plan says this does not meet the definition of a prosthesis.The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve is not covered, as it does not meet the definition of a prosthesis.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 sleeve. Our reviewer says that  Our physician reviewer found 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 sleeve have not been met.Therefore, we decided that the Plan does not have to pre-approvea mastectomy sleeve.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, synvisc or synvisc-one, for 
intra-articular injection. 
 
You asked the Plan to pre-approve Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular 
injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Hyaluronan or derivative, synvisc or synvisc-one, for 
intra-articular injection is only covered for certain indications. 
 
 
 
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 Hyaluronan or derivative, synvisc or 
synvisc-one, for intra-articular injection. Our reviewer says that the documentation does not support that the 
requested services are medically reasonable or necessary. Our physician reviewer found the documentation 
supports that the enrollee presented with pain, instability and limp in bilateral knees. The enrollee has not been 
taking anti-inflammatory medications on a regular basis. Prior treatments were not documented. X-rays were 
reported as demonstrating severe arthritis of the right knee with joint space narrowing osteophyte formation 
and sclerosis especially involving the lateral tibiofemoral compartment. Physical exam was notable for 
tenderness along the lateral joint line and patella, minimal effusion, valgus deformity and the presence of 
crepitus. Conservative therapy such as physical therapy was not documented in the medical records provided. 
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 Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyaluronan or derivative, 
synvisc or synvisc-one, for intra-articular injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee 
osteoarthritis. He has tried Orthovisc but not Monovisc. The Plan requires that both drugs be trialed first. The 
records do not support that the Monovisc would be contraindicated or less effective; therefore, Gel-One is not 
reasonable or medically necessary at this time. 
 
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 Gel-One.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Digoxin. 
 
You asked the Plan to pre-approve Digoxin. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Digoxin.  
 
Benefits for Digoxin may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required, tooth 
#30 (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the service is not a covered benefit under the plan. 
 
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. This service is not listed in your handbook as a covered benefit; 
therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve core buildup, 
including any pins when required, tooth #30 (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a nutritionist at Tertiary Level. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is in urgent need to proceed with a 
consult to a multidisciplinary team. The Plan denied your request. The Plan says the information does not show 
that the enrollee needs tertiary level care. 
 
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 
an office visit with a nutritionist at Tertiary Level.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 stabilizing, however, their prognosis is poor and 
the patient still requires additional short term acute care services to help determine long-term needs, which can 
be completed at the current facility. The patient does not require services at the LTACH that are not already 
available at the current setting. There are no services at the current facility that the patient requires that are not 
already available and covered at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. Transfer may be considered once treatment has completed and 
long-term care needs are more clear. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum erection device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that vacuum 
erection devices are not covered.  
 
The requested device is statutorily not covered by Medicare or the plan. Based on this information, we decided 
that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a vacuum erection device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for wheelchair van transport for the enrollee. 
 
You asked the Plan to provide coverage for this type of transport. You say that this transport is medically 
necessary. The Plan denied your request. The Plan says wheelchair van transport is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services. The services you have asked the Plan to provide coverage for are wheelchair van transport services. 
Therefore, we decided that the Plan does not have to provide coverage for wheelchair van transport for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient behavioral health therapy. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says this provider does 
not participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The requested provider is not enrolled in the Medicare program. 
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 outpatient behavioral health therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician service provided to the enrollee and billed 
under code 99239 for date of service of February 14, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says that the documentation submitted does not include a hospital discharge day management 
note with a recorded duration of time of 31 minutes or more for the billed date of service of February 14, 2020. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the records provided do not support 
the time-based services billed. Therefore, we decided that the Plan does not have to pay for the physician 
service provided to the enrollee and billed under code 99239 for date of service of February 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on March 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 25, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on March 
25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an out of network 
(OON) ophthalmologist. 
 
You asked the Plan to pre-approve an OON consultation. You say that you feel you are not getting the care you 
are want. The Plan denied your request. The Plan says there are in-netwoek ophthalmologists available for a 
second opinion. 
 
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 consultation to be provided by an out of network (OON) ophthalmologist.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of pelvis 
(72197). 
 
You asked the Plan to pre-approve the MRI. You say that a new doctor had took over for your urologist that 
had retired and the new doctor wants the MRI done so that he can know what approach to take next based of 
the MRI. The Plan denied your request. The Plan says this request for the MRI is not medically necessary at 
this time. 
 
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 the MRI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not indicate evidence of prostate cancer progression such as rising PSA or 
palpable nodule. MRI is not considered standard of care for patients in an active surveillance protocol unless 
there is concern for disease progression. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the magnetic resonance imaging (MRI) of pelvis (72197).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OT Evaluation (CPT code 97167 x 1 unit) to be 
provided by a tertiary provider. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is in urgent need to proceed with a 
consult to a multidisciplinary team. The Plan denied your request. The Plan says the member's OT evaluation 
can be done in an office setting. The Plan states the member was instead approved to have a consult with a 
contracted non-tertiary provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
OT Evaluation (CPT code 97167 x 1 unit) to be provided by a tertiary provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the 2 surface resin base for tooth # 15, and 
the 3 surface resin based composite filling on a posterior tooth (D2923) for teeth # 12 and 13 provided on July 
23, 2020. 
You asked the Plan to pay the full amount for the dental services. You say that you verified that fillings were 
covered at 100%. You also say that you received a bill that 3 of the fillings were not covered. The Plan denied 
your request. The Plan says that teeth # 12, 13, and 15 are posterior teeth. The Plan says that composite fillings 
for posterior teeth are paid at the downgraded rate of an amalgam filling. The Plan also says the 3 resin based 
composite fillings were covered, but at a downgraded benefit as stated in the Certificate of Coverage. 
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 and fillings are a covered service, 
composite fillings for posterior teeth are paid at the downgraded rate of an amalgam filling. You are 
responsible for the remaining amount. Therefore, we decided that the Plan does not have to pay the full amount 
for the 2 surface resin base for tooth # 15, and the 3 surface resin based composite filling on a posterior tooth 
(D2923) for teeth # 12 and 13 provided on July 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that a shower chair is medically necessary. The 
Plan denied your request. The Plan says a shower chair is not a covered benefit under your contractual policy 
or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).