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

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 7, 
2019, to February 21, 2019. 
 
You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 pay for SNF care. Our reviewer says that daily 
skilled services were not necessary. Our physician reviewer found the member did not require any skilled 
nursing or rehabilitation services on a daily basis at an inpatient level of care. She was not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or ADLs.  The member did not require skilled therapy to establish a safe and 
effective maintenance program.  As a practical matter, the member did not require any skilled services on an 
inpatient basis. The member did not have any parental medication, complex wound care or nutrition given via a 
feeding tube.  She was medically stable without any acute exacerbations of chronic medical problems.  Her 
physical function was at or near her baseline and she could have received further services at a lower level of 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from February 7, 2019, to February 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651, 
E0667). 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for this item to be covered, the enrollee must have 
Edema in the affected lower extremity. 
 
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 pneumatic compression device. Our 
reviewer says that the device is not medically necessary. Our physician reviewer found medical records do not 
document edema of the right lower extremity (RLE) and do not document skin changes. Rules for coverage are 
not met. 
 
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 pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651, E0667).
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 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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services but do not require an 
intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility 
due to decreased endurance and limited cognitive status. Care at the skilled nursing facility level appears to be 
more appropriate in this case. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network dialysis provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is an in-network provider with two locations available. 
 
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 
a referral to an out-of-network dialysis provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine eyewear (V2020, V2199). 
 
You asked the Plan to pre-approve additional routine eyewear. You say that the items are necessary. The Plan 
denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers standard lenses and frames, limited to 1 pair of lenses and frames once every 2 years. 
 
We looked at the file and the Plan's rules. You received frames with lenses on January 14, 2020. Based on this 
information, we decided that the Plan's rules for coverage of additional routine eyewear have not been met. 
Therefore, we decided that the Plan does not have to pre-approve additional routine eyewear (V2020, V2199).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for physician services by providers who are not 
eligible to participate in the Medicare program.  
 
You asked the Plan to provide coverage for you to see this provider. You say that you prefer to use the 
requested provider. The Plan denied your request. The Plan says the provider in question is not a Medicare 
eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider.  
 
The provider in question is not a Medicare eligible provider. The Plan has given you with the names of contract 
providers in your network who can provide treatment. Therefore, we decided that the Plan does not have to 
provide coverage for physician services from the requested provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 
10, 2019 to November 15, 2019. 
 
You asked the Plan to pay for SNF care. You say that SNF care was medically necessary. The Plan denied your 
request. The Plan says the enrollee did not meet criteria for coverage of 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 pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the patient did not require skilled nursing or 
skilled therapy services (or a combination of these services) on a "daily basis" in a SNF during the dates in 
appeal. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a 
skilled nursing facility setting during the dates in appeal. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from November 10, 2019 to November 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required for tooth 
# 21 (D2950), retrograde filling ? per root for tooth # 21 (D3430), gingivectomy or gingivoplasty to allow 
access for restorative procedure, per tooth for tooth # 21 (D4212), and add tooth to existing partial denture for 
tooth # 20 (D5650). 
 
You asked the Plan to pre-approve core buildup for tooth # 21, retrograde filling ? per root for tooth # 21, 
gingivectomy or gingivoplasty for tooth # 21, and add tooth to existing partial denture for tooth # 20. You say 
that the services are necessary. The Plan denied your request. The Plan says the requested services are 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 core 
buildup, including any pins when required for tooth # 21 (D2950), retrograde filling ? per root for tooth # 21 
(D3430), gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth for tooth # 21 
(D4212), and add tooth to existing partial denture for tooth # 20 (D5650).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
must receive your care from a network provider. In most cases, care you receive from an out-of-network 
provider will not be covered. 
 
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 
physician's services to be provided by the out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiological examination, surgical specimen services 
provided on January 10, 2020. 
 
You asked the Plan to pay for the radiological examination, surgical specimen services. The Plan denied your 
request. The Plan says you must receive your care from a network provider. In most cases, care you receive 
from an out-of-network provider will not be covered except for emergency care or urgently needed services 
that you get from an out-of-network provider. 
 
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 
services at issue. 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 a radiological examination, surgical specimen services provided 
on January 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography scan (LDCT) for lung 
cancer screening (G0297). 
 
You asked the Plan to pre-approve a LDCT for lung cancer screening. 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. Medicare rules say that lung cancer screening with LDCT is covered 
when specific criteria is met.  
 
 
 
 
 
 
 
 
 
 
We looked at the file and Medicare rules. Specifically, the enrollee is over the age of 77. Based on this 
information, we decided that Medicare rules for coverage of a LDCT for lung cancer screening have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography scan 
(LDCT) for lung cancer screening (G0297).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network 
provider. 
 
You asked the Plan to pre-approve the physical therapy. 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 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 physical 
therapy to be provided by the out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided to the enrollee 
from June 2, 2020, to July 1, 2020. 
 
You asked the Plan to pay for SNF care. You say that SNF care was medically necessary. The Plan denied your 
request. The Plan says the enrollee did not meet criteria for coverage of 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 pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the member did not require skilled therapy to 
establish a safe and effective maintenance program.  
 
 
As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of 
care at the time of discharge from the hospital. The member did not have any parental medication, complex 
wound care or nutrition given via a feeding tube. He was medically stable without any acute exacerbations of 
chronic medical problems. His physical function was at or near his baseline and he could have received further 
services at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided to the enrollee from June 2, 2020, to July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Theragun percussive therapy device. 
 
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. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Theragun percussive therapy device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic ultrasound provided on June 15, 2020. 
 
You asked the Plan to pay for the diagnostic ultrasound. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
services at issue. 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 a diagnostic ultrasound provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested device is not proven to be 
more beneficial for treatment of the enrollee's medical condition than any available standard of are therapy. At 
this time, the literature reveals there are few well controlled studies on the requested orthosis with inconsistent 
outcomes. The services are experimental/investigational in nature and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro Motion G Orthotic device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee presents with complaints of 
increased back pain over the last six to eight months. Current evidence based medical guideline and peer 
reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of 
lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the 
use of the Superion spacer for the enrollee's condition. The services are considered experimental in nature and 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over the counter syringe and needle provided to the enrollee 
on August 10, 2020 to August 13, 2020. 
 
You asked the Plan to pay for the syringe and needles. You say that you have a prescription and the items 
should be paid. The Plan denied your request. The Plan says the prescription was not valid and the items are 
not a DME item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are valid orders 
from the doctor.  
 
The record does not contain a valid physician order and relevant medical records which support medical 
necessity for the supplies provided in this case. The prescription you obtained is for August 27, 2020. This is 
after the date you bought the items from the store, which was August 10, 2020. Therefore, we decided that the 
Plan does not have to pay for over the counter syringe and needle provided to the enrollee on August 10, 2020 
to August 13, 2020.