Persius/hicric huggingface dataset:
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 admission. You say that all treating providers are highly recommending 
the SNF level of care. The Plan denied your request. The Plan says there is no documented need for daily 
skilled nursing 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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 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: 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 enrollee is ready for IRF. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on September 30, 2020 due to an enlarging abdominal aortic aneurysm and underwent surgery on 
October 7, 2020. As of October 8, 2020 she needs minimal assistance for stand to sit onto toilet and ambulating 75 
feet. 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's medical status does not 
currently require intensive physician and nursing oversight only in an IRF, and may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that her functional 
status requires an 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 24, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on September 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 72 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says this 
requested exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the requested additional trips will exceed the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve 72 additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care cannot provide the approach the 
enrollee needs. The Plan denied your request. The Plan says the enrollee does not demonstrate a need for 
complex interdisciplinary therapy. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital with multiple fractures suffered in a motor vehicle accident. 
The enrollee suffered bilateral pulmonary emboli. It is documented that the acute hypoxic respiratory failure 
had resolved. Distances have been limited by fatigue, but he was able to recuperate with seated rest breaks. The 
documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs 
requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical condition has stabilized. The documentation does not support that he has complex medical issues that 
require acute rehab nursing care, or monitoring by an inpatient rehab physician three times per week. While the 
enrollee is reasonably expected to benefit from continued physical and occupational therapy, the 
documentation does not support the need for an intensive therapy program with frequent physician oversight. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. The Plan denied your request. The Plan says SNF 
admission is not medically necessary. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled 
nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled 
nursing or therapy services on a daily 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
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. The Plan denied your request. The Plan says LTACH 
admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to require ongoing acute care services for the short term and 
is not sufficiently stable for discharge at this time due to leukocytosis. The enrollee does not require services at 
the LTACH that are not already available at the current setting. There are no services that the enrollee requires 
that are not already available and covered at the current 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 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing in all quadrants. 
 
You asked the Plan to pre-approve periodontal scaling and root planing in all quadrants. You say that this is an 
early adult periodontitis case with early bone less and several areas of radiographic calculus. You say that 
subgingival calculus is clinically detectable. The Plan denied your request. The Plan says that there is no 
evidence of significant bone loss that would require periodontal scaling and root planning. 
 
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 in all 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 in 
all quadrants. Our reviewer says that the criteria for coverage has been met. Our physician reviewer found that 
the presence of abnormal periodontal pockets in all four quadrants and the presence of subgingival calculus 
formation meet the criteria for coverage. 
 
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 in all quadrants have been met. Therefore, 
we decided that the Plan has to pre-approve periodontal scaling and root planing in all quadrants.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that your lower denture is broken. You say that 
you need a full set so that your upper denture will match your lower denture. You say that your current 
dentures cause your bite to be off and as a result cause pain when you chew. The Plan denied your request. The 
Plan says dentures are covered once every 5 years. 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 5 years has been reached. The record shows that the Plan paid for dentures that 
you received on August 3, 2017. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint injections. 
 
You asked the Plan to pre-approve the paravertebral facet joint injections. You say that the requested injection 
services are medically necessary. The Plan denied your request. The Plan says the enrollee has had shots in the 
past that did not help and some which made the pain worse. 
 
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 paravertebral facet joint injections. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee previously underwent laminectomy and rod fusion surgery L2 
? L4. The documentation does not include documented failure of conservative measures, including physical 
therapy. It is documented that several prior injections and blocks did not help, and some made her symptoms 
worse. In addition, there is potential non-facet pathology that could explain the enrollee's pain. 
 
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 paravertebral facet joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve paravertebral facet joint injections.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a diagnostic mammogram and ultrasound 
provided on June 3, 2020. 
 
You asked the Plan to waive the deductible for a diagnostic mammogram and ultrasound. You say that you 
were told that you would only owe a copayment and disagree with the charges. The Plan denied your request. 
The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You received a diagnostic mammogram and ultrasound on June 3, 2020. The record shows that you had paid 
$0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed 
amount of $195.90.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time a diagnostic 
mammogram and ultrasound were received on June 3, 2020. Therefore, we decided that the Plan does not have 
to waive the deductible for a diagnostic mammogram and ultrasound provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy and a comprehensive oral evaluation 
to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve the endodontic therapy and a comprehensive oral evaluation. You say that 
your dentist advised that a root canal is necessary. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among covered when they are received by an oral surgeon. Therefore, we decided that the Plan does not have 
to pre-approve endodontic therapy and a comprehensive oral evaluation to be performed by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213). 
 
You asked the Plan to pay for the maxillary partial denture. You say that you have had your current partial for a 
little over four years, and it has been adjusted several times. You also say that currently, your denture can no 
longer be repaired. The Plan denied your request. The Plan says you have exhausted your denture 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, dentures are covered once per arch 
every 5 years. The record shows that you received a maxillary partial denture on September 22, 2016, and your 
maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for a 
maxillary partial denture (D5213).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick 140mg autoinjector. 
 
You asked the Plan to pre-approve the Repatha autoinjector. You say that the enrollee is allergic to Lipitor and 
Crestor and needs this to reduce risk. The Plan denied your request. The Plan says this drug is self-administered 
and not covered by Part B. 
 
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 Repatha SureClick 140mg 
autoinjector.  
 
Benefits for the Repatha autoinjector may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics for heel and arch support (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that you need this because you balance is off due to 
misalignment. The Plan denied your request. The Plan says this item is not a covered benefit for your 
condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics for heel and arch 
support (L3020).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 11, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on May 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not the standard of care. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device is experimental. 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device for the enrollee.