Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out 
of network (OON) facility. 
 
You asked the Plan to pre-approve the OON PT services. You say that you have to go to PT three times a week 
and the only other network provider is 25 miles from your home which is too far for you to drive. The Plan 
denied your request. The Plan says review of the network shows that there is a provider within 11 miles of your 
home and another less than 14 miles from your home. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollee's home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide the services at issue. These 
providers are noted on the first page of this letter. Under Medicare rules, this means that contract providers are 
accessible to you. Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT) 
services to be provided by an out of network (OON) facility.
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 OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that this is the only doctor out of 400 you 
have contacted that can treat you illness. The Plan denied your request. The Plan says there are in-network 
specialist's that can provide the services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra battery for a POC. 
 
You asked the Plan to pre-approve an extra battery. You say that the battery on the POC you currently have 
only lasts two hours. The Plan denied your request. The Plan says Medicare does not cover new (extra) set of 
batteries. 
 
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 an extra battery have not been met. Medicare does not provide 
coverage for POC batteries as the item itself, the POC, can be recharged. When a POC is authorized, it includes 
the device itself, and an integrated battery or beneficiary-replaceable battery. Medicare does not cover new 
(extra) set of batteries. Therefore, we decided that the Plan does not have to pre-approve an extra battery for a 
POC.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are 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. 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 there is no evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. The documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. The enrollee's rehab needs can be safely and effectively met in an alternate, less intense setting such as at in-home with services. IRF admission is not medically necessary for this 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee tested positive for COVID-19 
and is a long term care resident. You say that skilled care is needed and that the clinical information provided 
supports that need. The Plan denied your request. The Plan says there is no documentation to support that the 
enrollee requires skilled nursing services. The Plan says that the enrollee's medical needs can be met as a long 
term care resident at the facility, with nursing oversight. The Plan says that the enrollee's condition can be 
treated at a lower level of 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 SNF services. 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, IV antibiotics 
or other ongoing SNF level skilled nursing needs. There is no indication that the enrollee's functional level 
needs 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, the 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that the medication 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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Zilretta. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the Zilretta is safe and effective or medically reasonable and necessary for the 
enrollee. Zilretta is not intended for repeat administration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (CPT Code 
97110 x10) and self-care/home management training (eg, activities of daily living (ADL) and compensatory 
training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive 
equipment) direct one-on-one contact, each 15 minutes (CPT Code 97535 x10). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the notes do not show the need for more therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific 
and effective therapy for your condition. You have had prior therapy for this condition and it does not appear 
that your functional level requires the ongoing unique skills of a professional therapist to safely and effectively 
provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. You have been authorized additional sessions which would allow review of an 
independent exercise program and ensure safety. The ongoing specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
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 therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop 
strength and endurance, range of motion and flexibility (CPT Code 97110 x10) and self-care/home 
management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety 
procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one 
contact, each 15 minutes (CPT Code 97535 x10).
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 OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan 
denied your request. The Plan says there are in-network provider able to provide 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 
the medical services to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopy, shoulder, surgical; debridement, extensive (CPT Code 29823) and arthroscopy, shoulder, surgical; with rotator cuff repair (CPT Code 29827).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says your records do not show that you have failed a trial of treatment given by your doctor for at least 3 months. The Plan states the requested procedure is not supported prior to a trial of treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical literature would not support proceeding to surgery at this time. An imaging study has not been performed to evaluate for rotator cuff pathology. There is no evidence of a recent reasonable and/or comprehensive conservative treatment trial and failure to support proceeding with surgery at this time. There are no red flag conditions noted to support urgent surgery for you. Therefore, this request for shoulder arthroscopy with extensive debridement and rotator cuff repair would not be considered 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopy, shoulder, surgical; debridement, extensive (CPT Code 29823) and arthroscopy, shoulder, surgical; with rotator cuff repair (CPT Code 29827).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with a Periodontist. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat. 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. The supplemental Dental Services benefit of your contract says that 
dental services are only covered when they are performed by a participating general dentist -dental services 
performed by a periodontist are not covered. Therefore, we decided that the Plan does not have to pre-approve 
a consultation with a Periodontist.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for shortness of breath, weakness 
and a facial droop. Your medical problems are stable. There are no identified problems that need inpatient 
medical management. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. The medical record supports a need for physical and occupational therapy but it does not 
support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says dental 
services performed by an oral surgeon 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.   
 
We looked at the file, and Medicare rules. Your plan only covers dental services when provided by a 
participating general dentist. Based on this information, we decided that the Plan's rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by 
an oral surgeon.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is not able to care for himself. The 
Plan denied your request. The Plan says daily skilled nursing and therapy services are not needed. 
 
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 physician reviewer 
found that the enrollee does not require skilled nursing services of a skilled professional nurse to safely and 
effectively provide medically necessary treatment in a SNF.  The enrollee does not have complex wound care 
or other ongoing SNF level skilled nursing needs. The enrollee's high functional level does not require skilled 
therapy services to safely and effectively provide medically necessary treatment in a SNF. He does not require 
skilled nursing or therapy 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of intraosseous basivertebral nerve, first two 
vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (CPT Code C9752). 
 
You asked the Plan to pre-approve the services. You say that the member is in pain and that the procedure is 
non-evasive and more effective. The Plan denied your request. The Plan says this service is considered 
experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy. It 
is not the care standard for low back pain treatment. 
 
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 destruction of intraosseous basivertebral nerve, first two vertebral bodies, including 
imaging guidance (e.g., fluoroscopy), lumbar/sacrum (CPT Code C9752).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services.. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that you have no skilled therapy or skilled nursing service needs. 
 
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 your condition does not meet 
Medicare criteria for continued 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 continued skilled nursing facility (SNF) services.