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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
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 there are no skilled medical needs and therapy needs can be met 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for 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 skilled nursing facility (SNF) services for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from January 9, 2019 to July 
10, 2020. 
 
You asked the Plan to pay for the services provided. You say that Medicare is not the primary payer in this 
case. The Plan denied your request. The Plan says the provider is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. A licensed professional counselor is not eligible to participate in 
Medicare. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the medical services provided from January 9, 
2019 to July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you need the wheelchair so you can freely 
go the supermarket and step outside the home without falling. The Plan denied your request. The Plan says 
there is no physical examination that is relevant to mobility needs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that your condition cannot be improved by a walker, cane or manual wheelchair. There 
are no records to show that you can safely operate the PMD being requested. This means that Medicare rules 
for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303). 
 
You asked the Plan to pre-approve a heavy duty extra wide hospital bed. You say that this is medically 
necessary. The Plan denied your request. The Plan says that your request is not medically necessary because 
you do not meet the weight requirement. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed if the 
beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds.  
 
We looked at the file and Medicare rules. The file indicates you do not weigh between 350 and 600 pounds. 
Based on this information, we decided that Medicare rules for coverage of a heavy duty extra wide hospital bed 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide 
hospital bed (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine injection services. 
 
You asked the Plan to pre-approve the Lidocaine injection services. You say that you were hit by a car in 2011 
and your back has never been the same. You say that the requested procedure helps you. You say that you 
cannot take anything else that works and that your spine doctor has sent him to physical therapy. The Plan 
denied your request. The Plan says the services in dispute are not considered the standard of care and the 
supporting documents do not include any extenuating circumstances. The Plan says that other standard 
treatments, such as exercise programs to decrease the pain, are generally recommended for a minimum of six 
months. 
 
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 Lidocaine injection services. Our 
reviewer says that Lidocaine injection services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has fibromyalgia and low back pain. He has been receiving 
intravenous infusions of Lidocaine 250mg on a monthly basis. He also uses Lidocaine cream. The request is for 
continuing monthly infusions. This is an off label experimental/investigational use of Lidocaine. Therefore, the 
request is deemed not medically reasonable or 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 Lidocaine injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Lidocaine injection services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sildenafil. 
 
You asked the Plan to pre-approve Sildenafil. The Plan denied your request. The Plan says drug coverage is 
limited only to those covered under the medical benefit. 
 
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 Sildenafil.  
 
Benefits for Sildenafil 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: 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 records provided support the need for 
care in a SNF. The Plan denied your request. The Plan says the medial records do not support that the enrollee 
meets the guidelines 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 pre-approve the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the documentation does not support 
that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse 
is required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The 
enrollee does not have complex wound care or other skilled nursing needs that requires a SNF stay. The 
enrollee's high functional level does not require skilled therapy services with the specialized skill, knowledge 
and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment only in a SNF. Skilled services are not needed on a daily basis or as practical matter 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Guardian Sensor 3. 
 
You asked the Plan to pre-approve the Guardian Sensor 3. You say that the enrollee has type 1 diabetes and had 
a pancreatectomy. You say that the enrollee needs the requested Guardian Sensors for her Medtronic 670G 
insulin pump. You say that the Medtronic 670G insulin pump is an insulin pump that uses the enrollee's CGM 
blood sugar readings and enters them into the pump. You say that the pump then automatically adjusts her 
insulin dosses based on her blood sugars. The Plan denied your request. The Plan says the items in dispute are 
not covered under Medicare or the enrollee's plan contract. 
 
The Plan must follow Medicare rules. Medicare rules say that the only CGMs which are covered are those that 
meet the specific criteria and are considered therapeutic. Medicare rules also say that if any of the coverage 
criteria for the CGM are not met, the related supplies will also be denied as not medically reasonable and 
necessary.  
 
We looked at the file and Medicare rules. The records show that the Guardian Sensor 3 being requested is used 
in combination with the Medtronic 670G insulin pump. The Guardian Sensor 3 is classified as a non-
therapeutic adjunctive device and is excluded from coverage. Therefore, we decided that the Plan does not have 
to pre-approve a Guardian Sensor 3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from 
September 3, 2019, to October 2, 2019. 
 
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the 
charges because you only used the device a few days. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for DME and related supplies.  
 
The Plan says that you received DME and related supplies from September 3, 2019, to October 2, 2019. 
Therefore, you are responsible to pay $719.04, which is less than the 20% coinsurance amount.  
 
You have been asked to pay $719.04 for DME and related supplies. DME and related supplies fall within the 
DME and related supplies benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME and 
related supplies provided from September 3, 2019, to October 2, 2019.
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 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 patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided on August 
3, 2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration 
because the records show your physician rendered the medically necessary services. The Plan denied your 
request. The Plan says two or more diagnosis codes associated to it are mismatched per the ICD-10-CM 
Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99285 is not supported in the record. Specifically, this claim was supported with 
diagnosis codes M17.11 and M17.12 indicating osteoarthritis of the left and right knees. There is a more 
appropriate primary bilateral diagnosis code that can be used. Based on this information, we decided that 
Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit (99285) provided on August 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus Gene Panel provided on September 15, 2020. 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration because 
this testing is useful for patients at initial diagnosis or for a patient with refractory disease. The Plan denied 
your request. The Plan says that this service was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the Tempus Gene Panel. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found given that this patient is a stage III status post resection molecular profiling could potentially 
identify molecular targets available for adjuvant 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 Tempus Gene Panel have been met. Therefore, we decided that the Plan has 
to pay for the Tempus Gene Panel provided on September 15, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on October 14, 
2020. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. 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 hospital outpatient clinic visit provided on October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous basivertebral nerve ablation. 
 
You asked the Plan to pre-approve intraosseous basivertebral nerve ablation. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 intraosseous basivertebral nerve 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. The requested 
Intracept procedure remains experimental for the treatment of low back pain. More research is needed to show 
safety and efficacy of the procedure. Therefore, the enrollee does not meet criteria for the requested 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 intraosseous basivertebral nerve ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intraosseous basivertebral nerve ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the requested hospital bed. You say that the nurses have trouble moving the 
enrollee around. The Plan denied your request. The Plan says the requested bed is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fillings (D2331 and D2391) provided on February 5, 2020. 
 
You asked the Plan to pay for fillings. You say that the services should be covered. The Plan denied your 
request. The Plan says two fillings are covered per a year at 50% when services are rendered by a participating 
provider. 
 
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. Specifically, the cost share applied to these services is correct. 
Therefore, we decided that the Plan does not have to pay for fillings (D2331 and D2391) provided on February 
5, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the member needs further physical, occupational 
and speech therapies. The Plan denied your request. The Plan says that the enrollee is receiving adequate and 
necessary intensive rehabilitation in the Inpatient Rehabilitation Facility. 
 
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 the enrollee's condition does not 
meet Medicare criteria for 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 skilled nursing facility (SNF) services for the enrollee.