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

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing for the upper right 
and upper left quadrants. 
 
You asked the Plan to pre-approve periodontal scaling and root planing for the upper right and upper left 
quadrants. You say that appealing the denial for periodontal scaling and root planing for the upper right and 
upper left quadrants. The Plan denied your request. The Plan says the criteria for coverage has not been met. 
 
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 periodontal 
scaling and root planing for the upper right and upper left quadrants 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 periodontal scaling and root planing for 
the upper right and upper left quadrants. Our reviewer says that the criteria for coverage has not been met. Our 
physician reviewer found that the periodontal pockets appear to be within acceptable limits and no horizontal 
bone loss was noted. 
 
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 periodontal scaling and root planing for the upper right and upper left quadrants 
have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and 
root planing for the upper right and upper left quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are out of these supplies. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (CPT Code E2377), harness for 
upgrade to expandable controller (CPT Code E2313) and electronic connection between wheelchair controller 
and two or more power seating system motors (CPT Code E2311). 
 
You asked the Plan to pre-approve the DME. You say that you are requesting review of denial of services. The 
Plan denied your request. The Plan says the DME is not necessary. 
 
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. Medicare guidance says that 
upgraded electronics (expandable controller, harness and electronic connector to 2 power options) are not 
medically necessary. Therefore, we decided that the Plan does not have to pre-approve expandable controller 
(CPT Code E2377), harness for upgrade to expandable controller (CPT Code E2313) and electronic connection 
between wheelchair controller and two or more power seating system motors (CPT Code E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for total hip arthroplasty revision (CPT 27134) provided to the 
enrollee on March 4, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 27134-Rt is not supported by the medical records submitted. 
 
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 CPT Code Manual definition of code 27134 is "revision of total hip arthroplasty for both 
components, with or without autograft or allograft." 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
operative report does not include revision of both compartments. The documentation includes revision of 
Acetabular shell and liner, however, documentation does not support revision of Femoral component. 
 
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 pay for total hip arthroplasty revision (CPT 27134) provided to the enrollee on March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you cannot use the bathroom without 
your wife's assistance. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural injections of the cervical spine. 
 
You asked the Plan to pre-approve epidural injections (64479, 64480). You say that the enrollee needs the 
epidural injections for cervical pain, numbness and tingling. The Plan denied your request. The Plan says the 
enrollee has had this type of injection before and did not have improvement. 
 
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 epidural injections (64479, 64480). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that the enrollee has a history of chronic neck pain 
with radicular symptoms into both shoulders and hands.  
 
Treatment has consisted of medical therapy including opiates and physical therapy. The enrollee underwent a 
cervical transforaminal epidural steroid injection right C5/C6 on November 19, 2019 and reported 80-90% pain 
relief with an increase in function. In July 2020, the enrollee presented with continued neck pain with 
radiculopathy to both shoulders and hands.  
 
Per the coverage criteria: The Plan's Clinical Policy Bulletin (CPB) Number 0722: 
Repeat injections are supported when there has been at least 2 of the following for 2 or more weeks in duration: 
1) 50% or greater relief in pain, 2) increase in the level of function/physical activity (e.g., return to work), 
and/or 3) reduction in the use of pain medication and/or additional medical services such as physical 
therapy/chiropractic care. 
 
The clinical information provided does not meet the above criteria. The review has determined that the 
requested cervical epidural steroid injections are 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 epidural injections (64479, 64480) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve transforaminal epidural injections of the cervical spine.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says there is a wide range of neurosurgeons within the network with 
experience that can offer you 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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee needs chemotherapy to control her 
disease and you propose to use Keytruda in combination with chemotherapy. The Plan denied your request. 
The Plan says the denial of authorization for Keytruda is correct, because this drug is not supported for use in 
combination with carboplatin and pemetrexed. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
enrollee does not meet the Medicare criteria for Keytruda. Our physician reviewer found the requested use of 
Keytruda is not approved by the Food & Drug Administration (FDA). The requested use is not listed as 
indicated, recommended, or supported in any Medicare-approved compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this device would be helpful and 
should be covered. The Plan denied your request. The Plan says there is not sufficient medical evidence to 
support the necessity of this device at this time. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested spacer remains experimental in cases of spinal fusion surgery. More 
research is needed to show the safety and efficacy of the device. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a Superion interspinous spacer device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in 
the home health or hospice setting, each 15 minutes (CPT Code G0151 x 2) and direct skilled nursing services 
of a RN in the home health or hospice setting, each 15 minutes (CPT Code G0299 x 1). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 services. Our physician reviewer 
found based on the medical records provided there is no documentation that shows that the denied four skilled 
therapy visits are required to effectively provide treatment, care, and/or services in order to improve the 
enrollee's level of function, or to establish/perform a maintenance program to maintain your level of function 
and/or prevent deterioration. No detailed records are available in the file documenting your physical limitations 
or needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve services performed by a qualified physical therapist in the home health or hospice setting, 
each 15 minutes (CPT Code G0151 x 2) and direct skilled nursing services of a RN in the home health or 
hospice setting, each 15 minutes (CPT Code G0299 x 1).
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 still cannot transfer from the 
bed to chair or toilet but her doctors believe she will be able to soon with continued daily therapy. She is also 
likely to be able to benefit from ongoing speech therapy to allow for better swallowing. She also requires 
nursing care for hydration and nourishment due to her inability to swallow. The Plan denied your request. The 
Plan says the enrollee's needs can be met with less than daily skilled services. 
 
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 female with 
history of stroke, currently in inpatient rehabilitation. Issue in appeal is whether the enrollee meets the 
Medicare criteria for SNF admission. From a nursing perspective, the beneficiary received oral medications. 
The beneficiary had stable vital signs. Her lungs were clear. Regarding rehabilitation services, the beneficiary 
received PT, ST and OT in the acute hospital. The beneficiary was at a dependent to maximal assist level with 
bed mobility and transfers (or required a mechanical lift). She could ambulate 4 feet with maximal assist in the 
parallel bars. The beneficiary required varying assist with ADLs. She tolerated a pureed diet and nectar 
thickened liquids. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but 
there is no need for daily skilled therapy services. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manual therapy services to be provided by a 
chiropractor. 
 
You asked the Plan to pre-approve the manual therapy. You say that this treatment has been tried in the past 
and was helpful. The Plan denied your request. The Plan says this service cannot be approved if performed by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve manual therapy services to be provided by a chiropractor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient psychiatric care beyond September 
22, 2020. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee remains with 
intermittent suicidal thoughts and needs continued care in the inpatient setting. The Plan denied your request. 
The Plan says the enrollee has exhausted the lifetime inpatient psychiatric benefit and no further care can be 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for inpatient psychiatric care is limited 
to 190-days in a patient's lifetime. The contract with the Plan also states this. 
 
Based on the Medicare database, the enrollee has received 190 days of inpatient psychiatric care. As such, no 
further inpatient psychiatric coverage is available. Therefore, we decided that the Plan does not have to pre-
approve additional inpatient psychiatric care beyond September 22, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says medical 
necessity was not established for a SNF admission. 
 
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 the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. 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 a SNF admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet neurolysis. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that facet neurolysis is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic back pain, 
lumbar radiculopathy, and lumbar spondylosis. No records were submitted with documented physical exam 
findings. There is no documentation of conservative care. The requested procedure is supported for 
predominantly axial pain that is not associated with radiculopathy or neurogenic claudication. The services do 
not meet the criteria for coverage and are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet neurolysis.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint nerve destruction treatment. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the notes do not show that both of the facet nerve test blocks provided the 
indicated level of relief. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint denervation is covered when there are 
dual medial branch blocks with 80% or more relief.  
 
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 treatment. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the health plan wrongly states that there is no documentation that there was significant pain relief form 
each of the two sets of diagnostic medial branch blocks. It is clearly documented that greater than 80% pain 
relief was achieved each time. The requested procedure is 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 treatment have been met. Therefore, we decided that the Plan has to pre-
approve facet joint nerve destruction treatment.  
 
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.