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

 
We decided that the Plan does not have to pre-approve dental extractions (CPT Code D7210) to be performed 
by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that your provider referred you to an oral 
surgeon because you have two (2) teeth that are broken at the gumline and nine (9) additional teeth that need to 
be extracted. The Plan denied your request. The Plan says the service is not a covered benefit when performed 
by an oral surgeon. 
 
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. Dental services are only covered when they are performed by a 
participating general dentist -dental services performed by an oral surgeon are not covered. Furthermore, you 
are only covered for one (1) extraction procedure per year. Your EOC states, "services must be performed by a 
participating general dentist. Simple extraction or surgical removal of erupted tooth / one (1) procedure per 
year." Therefore, we decided that the Plan does not have to pre-approve dental extractions (CPT Code D7210) 
to be performed by an oral surgeon.
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 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. 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 enrollee was admitted to the hospital August 22, 2020 with acute kidney injury. The enrollee still requires acute hospital level of care service and is receiving appropriate care at the present acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis 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-approve personal care. 
 
You asked the Plan to pre-approve personal care. You say that the enrollee has multiple medical problems and 
requires personal attendant to assist with their care. The Plan denied your request. The Plan says custodial care 
is personal care that does not require the continuing attention of trained and medical or paramedical personnel, 
such as care that helps the enrollee with activities of daily living, such as bathing or dressing. 
 
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 looked the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of personal care have not been met. Custodial care is not a covered benefit under any circumstance under the 
member's plan. Therefore, we decided that the Plan does not have to pre-approve personal care.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the requested LTACH care 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with acute respiratory failure with hypoxia requiring intubation on August 4, 2020. He 
is receiving appropriate care at the present acute care hospital. He does not require services at the LTACH that 
are not available at the acute care hospital where he is currently receiving care. There are no services available 
at the LTACH that the enrollee requires that are not available at the health care setting being offered by the 
health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration (20939). 
 
You asked the Plan to pre-approve the bone marrow aspiration. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says there is no medical 
evidence that the use of one marrow aspirate increases fusion rates in cases such as this. 
 
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 bone marrow aspiration. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found bone marrow aspiration remains experimental for use in spine surgery. 
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 bone marrow aspiration have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bone marrow aspiration (20939).
Appeal type: Practitioner Services
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 this service is for a continuation of care. 
The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac radiofrequency ablation. 
 
You asked the Plan to pre-approve sacroiliac radiofrequency ablation. You say that the requested sacroiliac 
radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the requested 
sacroiliac radiofrequency ablation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve sacroiliac radiofrequency ablation. Our 
reviewer says that the requested sacroiliac radiofrequency ablation is not medically necessary. Our physician 
reviewer found the enrollee is with right sacroiliac joint pain and diagnosis of sacroilitis. SI joint ablation 
therapy remains experimental. More research is needed to show the safety and efficacy of the procedure. The 
request is not 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 sacroiliac radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve sacroiliac radiofrequency ablation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of 
SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for continued SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was 
admitted following functional decline due to acute care hospital stay for a fall with resulting left distal femur 
fracture, and underwent surgery, now non-weight bearing to left lower extremity. Hospital course has included 
management of pain. She has no active synovitis per recent reports. She is non-ambulatory and minimal assist 
is needed for basic bed mobility. She requires significant assistance for activities of daily living and transfers.  
 
The enrollee is now requiring significant assist for activities of daily living and transfers.  The enrollee has no 
complex wound care needs, or IV medication requirements.  There are no nursing or therapy needs that are 
skilled, and warranting a SNF as opposed to a lesser level of care, such as placement into a custodial care 
center. As such, SNF care 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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
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 the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. The Plan say that the 
care needed could be received in another setting. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgery for esophageal cancer. Medical problems are stable and tube feedings are tolerated. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. The record does support a need for physical and occupational therapy, but there is no need for an 
intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core. 
 
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 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 a 
prefabricated post and core.
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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not have complex wound care or other ongoing SNF level skilled nursing need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter, this enrollee does not require the necessary services on 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 admission to a SNF 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 a third epidural steroid injection. 
 
You asked the Plan to pre-approve the injections. You say that you would like reconsideration because this 
injection is medically necessary. The Plan denied your request. The Plan says you can have two injections into 
your spine at one time and your doctor has requested more than two for the same day. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than two epidural injections may be 
performed at a single session. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injections have not been met. Specifically, the record indicates that the Plan has approved two 
epidural injections for this session. Your doctor is requesting a third injections, but per Medicare, it is not 
considered medically necessary to have more than two epidural injections performed in a single session. 
Therefore, we decided that the Plan does not have to pre-approve a third epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are equally qualified in-network oncology specialists available 
to you that can provide the care and treatment you are requesting. 
 
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 office visit services 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 Synvisc-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 primary osteoarthritis 
of the knees. She had benefit from steroid injections in the past but did not have long-lasting relief. She has not 
tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required 
drugs would be contraindicated or less effective; therefore, Synvisc-One is 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 Synvisc-One.
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 admission to a SNF. You say that the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for admission to a 
SNF. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
have complex wound care or other ongoing SNF level skilled nursing need. The enrollee's functional level does 
not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist 
to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a 
SNF. As a practical matter, this enrollee does not require the necessary services on 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).