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

We decided that the Plan does not have to pre-approve the MRI pelvis; without contrast material(s), followed
by contrast material(s) and further sequences (CPT Code 72197), for the enrollee.
You asked the Plan to pre-approve the MRI. You say that you are asking for a MRI of the prostate for the
enrollee. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
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 the MRI. Our physician reviewer found
there was no clear justification made for skipping prostate biopsy or prostate specific antigen (PSA) monitoring
which is the standard of care in this clinical indication. There was no contraindication to biopsy. Therefore,
without sufficient support made for this request, the prostate MRI will be considered 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 the MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve the MRI pelvis; without contrast material(s), followed by contrast material(s) and further
sequences (CPT Code 72197), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's service. You say that you were not satisfied with the in-
network physician and his staff. The Plan denied your request. The Plan says you are authorized to see in-
network equally qualified providers, as is required by the contract. Out-of-network providers are allowed only 
when the service is medically necessary but unavailable within the network or in an emergency.  As this is not 
the case there is no medical necessity for an out-of-network provider at the present time. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of broken teeth provided. 
 
You asked the Plan to pre-approve replacement of broken teeth. You say that you are appealing the denial. 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 pre-approve 
replacement of broken teeth provided.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
December 9, 2019 to December 23, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Home health care services must be billed on a UB-04 form per 
Medicare guidelines. The case file shows the home health services were submitted incorrectly. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from December 
9, 2019 to December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated post and core in addition to crown 
(D2954) for tooth #'s 20 & 21. 
 
You asked the Plan to pre-approve prefabricated post and cores. You say that the enrollee needs a root canal 
treatment and post and core for tooth #'s 20 & 21. The Plan denied your request. The Plan says this service 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 in addition to crown (D2954) for tooth #'s 20 & 21.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2751) for tooth #14.
You asked the Plan to pre-approve the crown. You say that tooth #14 has large defective fillings with recurrent
caries. The Plan denied your request. The Plan says that the documentation provided demonstrates 50% or
more bone loss and a poor crown to root ratio. The Plan also says that their finding results in a poor long term
prognosis for this tooth.
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 the crown
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 the crown. Our reviewer says that the
service is medically necessary. Our physician reviewer found there is a large restoration in the tooth and mesial
caries and/or fracture. Our physician reviewer found that radiographically, a significant portion of the coronal
structure is compromised, and a crown restoration is medically reasonable and necessary to restore tooth #14 to
adequate function.
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 the crown have been met. Therefore, we decided that the Plan has to preapprove
a crown (D2751) for tooth #14.
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 home health aide (HHA) services. 
 
You asked the Plan to pre-approve the HHA services. You say that you believe that you may be leaving your 
current facility soon and will need an HHA to help you in the home. The Plan denied your request. The Plan 
says based on communication with the staff at your facility, you are currently receiving the appropriate level of 
care and there is no plan for you to be discharged. A doctor has not ordered home health care for you. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
There is no documentation showing that you are soon to be discharged to the home or that skilled nursing or 
therapy services have been ordered in the home health setting. As such, the rules for coverage of HHA services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide (HHA) 
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for  the physical therapy services billed on December 23, 2019. 
 
You asked the Plan to pay for  the services provided. The Plan denied your request. The Plan says the billed 
services were not supported by the submitted documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services provided. Our reviewer says that  
the medical records submitted do not include documentation to verify that 97110 - a Therapeutic procedure, 1 
or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and 
flexibility was performed on December 23, 2019. Therefore, this service cannot be verified. The medical 
records submitted do not include documentation to verify that 97112 - Therapeutic procedure, 1 or more areas, 
each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, 
and/or proprioception for sitting and/or standing activities was performed on December 23, 2019, therefore this 
service cannot be verified. The medical records provided do not include documentation to validate that the 
required time spent for 97140 - Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic 
drainage, manual traction), 1 or more regions, each 15 minutes was performed on December 23, 2019, 
therefore this service cannot be verified. 
 
We looked at this coder?s review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for  the physical therapy services billed on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you are not requesting the acupuncture services for 
chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 17, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician?s intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on December 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 injections (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the Gelsyn-3 is medically necessary. The Plan 
denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be 
considered. 
 
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 Gelsyn-3. Our reviewer says that the 
Gelsyn-3 is not medically necessary. Our physician reviewer found the record does not show a trial of the plan 
preferred drugs. The record does not show any reason the plan preferred drugs would be unsafe or ineffective 
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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 injections (J7328).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trigger point injections rendered on January 8, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that anatomical modifiers must be billed appropriately. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 20552 
(injection[s]; single or multiple trigger point(s), 1 or 2 muscle[s]) with the -RT modifier. This code is a 
unilateral procedure; however, and billing with the -RT modifier is not appropriate. Therefore, we decided that 
the Plan does not have to pay for the trigger point injections rendered on January 8, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve bilateral facet injections.
You asked the Plan to pre-approve the requested injections. You say that you have tried acetaminophen, Tramadol, and physical therapy. The Plan denied your request. The Plan says that the records show that you have radiculopathy.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. 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 requested injections. Our physician reviewer found that you have chronic low back pain. You have been taking Tylenol, have tried physical therapy in the past, and are currently doing a home exercise program. You are using a walker to do 20-minute walks each day. Based on the documentation provided, the request is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested injections have been met. Therefore, we decided that the Plan has to pre-approve bilateral facet injections.
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. You say that the requested Supartz is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Monovisc AND Orthovisc first. 
 
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 Supartz. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the documentation 
provided, the enrollee is noted to have post-traumatic right knee osteoarthritis. A request has been made for 
Supartz, a hyaluronic acid injection, to treat the osteoarthritis. The health plan requires that other forms of 
hyaluronic acid injections be used. There is no evidence that the enrollee is allergic to or intolerant of these 
other forms of hyaluronic acid. There is no evidence that the enrollee has tried and not responded to these other 
forms of hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid 
would not be expected to be safe and effective for the enrollee. Therefore, the requested Supartz is not shown 
to be currently medically necessary and reasonable. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.
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 SNF admission. You say that the enrollee can no longer lift herself, her 
family cannot take care of her, and she does not have the ability to pay for a home caretaker. The Plan denied 
your request. The Plan says the denial of authorization for SNF service is correct. 
 
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 the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. 
Although the enrollee does have skilled therapy needs, these needs are not on a daily basis. The enrollee does 
not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a Skilled Nursing Facility (SNF) 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 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 for the enrollee.
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 the member's rehab needs can be met in a lower level of care.
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
patient is medically stable with no evidence of need for supervision by physical medicine and rehab physician
or need for acute rehab nursing care. Functionally given her current level, she does not require IRF level of
therapies. The patient may benefit from further physical therapy and occupational therapy but does not require
an intensive therapy program. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that this physician has proved to be more 
competent then all the available in-network doctor's and your PCP has not recommended any other providers. 
The Plan denied your request. The Plan says the Plan does not have evidence that you are unable to see a 
provider within the referral circle or that seeing a provider within the referral circle would not meet your needs. 
 
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 contract with 
the Plan also says that each plan PCP has certain plan specialists called a referral circle that s/he uses for 
providing medical care to you. This means that in most cases, you will not have access to the entire Plan's 
network, except in emergency or urgent care situations or for out-of-area renal dialysis or other services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
within your PCP referral circle available who can provide the services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does 
not have to pre-approve the requested physician's services.