Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the member will benefit from short-term 
rehabilitation at a skilled nursing facility. The Plan denied your request. The Plan says that these services are 
not reasonable and necessary for the treatment of the patient's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment. You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. 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 inpatient mental health treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of October 16, 2020 forward and could have been treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, or delusions and you were not showing any behaviors or aggression. You were being cooperative and compliant while not showing any acute threats to the safety of yourself or others. 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 mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a soft cervical collar (L0120). 
 
You asked the Plan to pre-approve a soft cervical collar. You say that the item is necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a soft cervical collar. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the soft 
cervical collar at issue in this case is medically reasonable and necessary as defined by the Medicare Braces 
Benefit. It is not sufficiently rigid to be capable of providing the necessary immobilization or support to the 
body part for which it is designed and thus does not meet the statutory definition of the Medicare Braces 
Benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a soft cervical collar have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a soft cervical collar (L0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontic and retainer crown. 
 
You asked the Plan to pre-approve the pontic and retainer crown. You say that this should be covered. The Plan 
denied your request. The Plan says the services are not covered benefits. 
 
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. Therefore, we decided that the Plan does not have to pre-approve the 
pontic and retainer crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prefabricated post and core (D2954). 
 
You asked the Plan to pre-approve the dental service. You say that it is important you finish your teeth. You 
say that you do not have money right now with COVID-19. You also say you cannot wear your partial without 
your tooth. The Plan denied your request. The Plan says prefabricated post and core is not listed as a covered 
service. The Plan also says if a dental item or service is not listed in the benefit chart or listed with NC, then it 
is not covered. 
 
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. Therefore, we decided that the Plan does not have to pre-approve the 
prefabricated post and core (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coping (D2975), endosteal implant (D6010), second 
stage implant surgery (D6011), prefabricated abutment (D6056), and implant supported crown (D6067). 
 
You asked the Plan to pre-approve the coping, endosteal implant, second stage implant surgery, prefabricated 
abutment, and implant supported crown. You say that you were told that the provider could rebuild your teeth. 
The Plan denied your request. The Plan says these services are not covered. 
 
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. Therefore, we decided that the Plan does not have to pre-approve 
coping (D2975), endosteal implant (D6010), second stage implant surgery (D6011), prefabricated abutment 
(D6056), and implant supported crown (D6067).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRemicade.You asked the Plan to pre-approveRemicade. You say that the enrollee has a history of psoriatic arthritis, and was previously treated with Otezla, Enbrel, Methotrexate, and Arava.The Plan denied your request. The Plan says the enrolleehas not had a previous trial of Renflexis or Inflectra.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 Remicade. Our physician reviewer foundthat the enrollee has a diagnoses of psoriasis and psoriatic arthritis. The Plan requires a trial ofRenflexis or Inflectra before they will approve the requested drug. The documentation does not show that the enrollee has tried the required drugs.There is no indication that the plan's required drug(s) would likely be less effective, 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 Remicade have not been met.Therefore, we decided that the Plan does not have to pre-approveRemicade.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spiriva Respimat. 
 
You asked the Plan to pre-approve Spiriva Respimat. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B plan. 
 
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 Spiriva Respimat.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) provided on 
June 4, 2020. 
 
You asked the Plan to pay for the unspecified preventive procedure (D1999). You say that you only had an 
exam. You say that you are appealing the service of $50. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive procedure (D1999) provided on June 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 sinus augmentations (D7951) and a cone beam CT capture (D0366).
You asked the Plan to pre-approve the dental services. You say that you have no bone and when you chew your food your whole mouth hurts, your face hurts and you get migraines. You say that your gum is shrinking. You also say that it contains zinc which is harmful to your health. The Plan denied your request. The Plan says sinus augmentation is not listed as a covered service. The Plan says cone beam CT capture is not listed as a covered service either.
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. Therefore, we decided that the Plan does not have to pre-approve 2 sinus augmentations (D7951) and a cone beam CT capture (D0366).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the patient screening and occlusion analysis. 
 
You asked the Plan to pre-approve the patient screening and occlusion analysis . You say that the mouth guard 
is treating your sleep apnea and will keep your airways open. You say that your treatment options should be 
approved. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve 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 pre-approve the patient screening 
and occlusion analysis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that it's become dangerous and can not move alone 
in the shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that continuing with the therapist that knows you 
and has helped for years will be more beneficial than starting with a program that hasn?t previously succeeded. 
The Plan denied your request. The Plan says services are available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated post and core (D2954 x 2) and core build 
up (D2950 x 5). 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are necessary. The 
Plan denied your request. The Plan says prefabricated post and core is not listed as a covered service. The Plan 
says core build up is not listed as a covered service. The Plan also says if a dental item or service is not listed in 
the benefit chart or listed with NC, then it is not covered. 
 
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. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated post and core (D2954 x 2) and core build up (D2950 x 5).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental sedation services to be provided by a non-
Medicare provider. 
 
You asked the Plan to pay for the dental sedation services. You say that you feel that this should be covered. 
The Plan denied your request. The Plan says this provider is not enrolled in Medicare and cannot be paid for 
these services. 
 
The Plan must follow Medicare rules. Medicare rules say that payment cannot be made to a provider who is not 
enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
sedation services to be provided by a non-Medicare provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care evaluation and management 
services billed with CPT code 99233. 
 
You asked the Plan to pay for CPT code 99233. You say that your physician billed CPT code 99233 as a level 
3 hospital inpatient follow up. You say that the physician provided this subsequent hospital care for an unstable 
patient with significant problems. You say that the medical records should be reviewed and payment for this 
code reconsidered. The Plan denied your request. The Plan says the code in dispute was appropriately denied 
according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a subsequent hospital visit is not paid for in 
addition to hospital discharge day management service on the same day by the same physician. 
 
We looked at the file and Medicare rules. The records show that the subsequent hospital care that is in dispute 
was reported with hospital discharge day management services (99238) by the same provider for the same date 
of service. The rules clearly state that, in instances where both subsequent hospital visits services and hospital 
discharge day management services have been billed by the same provider and on the same date of service, 
only the hospital discharge management code should be paid.  
 
 
Based on this information, we decided that Medicare rules for coverage of CPT code 99233 have not been met. 
Therefore, we decided that the Plan does not have to pay for subsequent hospital care evaluation and 
management services billed with CPT code 99233.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental item. You say that the denture is necessary. The Plan denied your 
request. The Plan says dentures are covered once every 60 months. The Plan says that the frequency limit has 
been reached. 
 
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 dentures are a covered service, the 
frequency limit of once every 60 months has been reached. The record shows you received a partial lower 
denture. Therefore, we decided that the Plan does not have to pre-approve a complete lower 
denture (D5120).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says that the enrollee does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's 
failure to obtain records that are within the plan's control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the requested continuous glucose monitor 
(CGM). Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing home health visits. 
 
You asked the Plan to pre-approve the skilled nursing visits. The Plan denied your request. The Plan says the 
requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing visits. Our reviewer 
says that the requested skilled nursing visits are not medically reasonable and necessary. Our physician 
reviewer found that the records do not show that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration.  
 
The enrollee has had prior skilled nursing for disease and medication management and education. The enrollee 's 
conditions are chronic and there is no evidence of complex wound care or other skilled nursing 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 skilled nursing visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing home health visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99201) 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 this care. 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 (99201) to be provided by an out of network (OON) provider.