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

 
We decided that the Plan does not have to pre-approve partial removal of spine bone with release of upper 
spinal cord and/or nerves. 
 
You asked the Plan to pre-approve partial removal of spine bone with release of upper spinal cord and/or 
nerves. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity 
has not been established. Therefore, coverage criteria have not been met. 
 
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 partial removal of spine bone with 
release of upper spinal cord and/or nerves. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found criteria for cervical 
surgery not met. There is no adequate trial of physical therapy for neck pain in the records. More conservative 
measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial removal of spine bone with release of upper spinal cord and/or nerves have not been met. Therefore, we decided that the Plan does not have to pre-approve partial removal of spine 
bone with release of upper spinal cord and/or nerves.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA). 
 
You asked the Plan to pre-approve a CTA. You say that the enrollee has an asymmetrical aortic aneurysm 
(AAA) which the enrollee states is above the renal arteries. You also say that there has been no CT scan 
performed as the enrollee has reservations about intravenous contrast for the CT scan. The Plan denied your 
request. The Plan says the requested CTA is 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 a CTA. Our reviewer says that the 
requested CTA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the national data and consensus criteria does not indicate a CT scan is needed for surveillance. The 
documentation indicates that the test required for monitoring is an ultrasound. Therefore, the reviewer found 
that the requested service is not 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 a CTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a computed tomography angiography (CTA).
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 will clearly benefit from acute 
rehabilitation to optimize her level of functioning prior to returning home. The enrollee has a serious, life 
threating constellation of acute medical problems that have left her at a functional status below her baseline. 
The Plan denied your request. The Plan says the criteria for admission to the acute inpatient rehabilitation 
setting 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 in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim abutments (code D6051) and temporary fixed 
lower denture supported by an implant upper arch (code D6118). 
 
You asked the Plan to pre-approve the abutments (code D6051) and temporary lower denture (code D6118). 
You say that you would like these services reconsidered for payment. The Plan denied your request. The Plan 
says codes D6051 and D6118 are not listed on the dental benefits chart and are non-covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
interim abutments (code D6051) and temporary fixed lower denture supported by an implant upper arch (code 
D6118).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after July 8, 2022. 
 
You asked the Plan to pre-approve SNF care after July 8, 2022. You say that the continued admission to a SNF 
is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF 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 in the Medicare rules section 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 care after July 8, 2022. Our 
reviewer says that the enrollee does not meet the Medicare criteria for continued SNF care. Our physician 
reviewer found based on the medical records provided there is no documentation that the enrollee requires the 
services on an inpatient basis, only in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after July 8, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the crown (D2740) on tooth #14 to be provided by a network 
provider. 
 
You asked the Plan to pre-approve the crown (D2740) on tooth #14. You say that the enrollee meets the 
standard of care, and the authorization denial should be overturned. The Plan denied your request. The Plan 
says that there is no evidence of decay or missing crown to support the need for replacement. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crown 
(D2740) on tooth #14 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 (D2740) on tooth #14. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the documentation 
indicates that the present crown has open margins and recurrent caries. This crown was placed over 20 years 
ago. Due to the open margins and recurrent caries, a replacement crown is medically reasonable and necessary 
to preserve the integrity of tooth #14. 
 
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 (D2740) on tooth #14 have been met. Therefore, we decided that the 
Plan has to pre-approve the crown (D2740) on tooth #14 to be provided by a network provider.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient services provided from May 15, 2021, through May 29, 2021, 
at DRG 853. 
 
You asked the Plan to pay for inpatient services at DRG 853. You say that the medical record is very clear with 
no contradiction, thus the diagnosis was coded. You say that DRG 853 is validated, and the claim should be 
processed with the original DRG based payment. The Plan denied your request. The Plan says that the 
physician doesnt document the likely tubular necrosis at time of discharge. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N17.0, defined as acute 
kidney failure with tubular necrosis. 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 
inpatient services at DRG 853. Our reviewer says that the documentation supports the secondary diagnosis 
code N17.0. Our physician reviewer found in order to support the diagnosis code; the likely diagnosis must be 
documented in the medical record at time of discharge per coding guidelines. The nephrology progress note 
dated May 28, 2021 states acute kidney injury likely acute tubular necrosis. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
services provided from May 15, 2021, through May 29, 2021, at DRG 853.  
 
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 chiropractic care provided on April 1, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON chiropractic care. You say that these services were provided in good 
faith by a provider who participates with Medicare. The Plan denied your request. The Plan says unauthorized, 
non-plan care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for chiropractic care 
provided on April 1, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the problem focused oral evaluation (code D0140) and an intraoral 
periapical first radiographic image (code D0220) provided on February 3, 2022. 
 
You asked the Plan to pay for the oral evaluation (code D0140) and first radiographic image (code D0220). The 
Plan denied your request. The Plan says that the x-ray service is covered once every 3 years and you last 
received that service on February 26, 2021. The Plan says the oral exam is covered only once every 6 months 
and was received on January 21, 2021.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide any proof that they paid for an earlier x-ray and 
evaluation which exhausted your benefits.  Therefore, we decided that the Plan has to pay for the problem 
focused oral evaluation (code D0140) and an intraoral periapical first radiographic image (code D0220) 
provided on February 3, 2022.  
 
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 pre-approve sedation during an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve sedation. You say that you have tried oral anxiolytics long before but it did 
not work at all. You say that you cannot deal with the spinal headache. You say that you cannot stop vomiting 
due to intense pressure on your brain. You also say that you are supposed to be still while taking this 
medication, but you are not able to. The Plan denied your request. The Plan says the requested service is 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 sedation. Our reviewer says that the 
requested sedation for an ESI is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of sedation has been found to increase the risk of significant morbidity and may interfere with evaluation of the results.  The use of oral sedatives has not been tried here.  The request is 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 sedation have not been met. Therefore, we decided that the Plan does not have 
to pre-approve sedation during an epidural steroid injection (ESI).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
  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 Aranesp. Our reviewer says that 
Aranesp is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Retacrit or Procrit before they will approve the requested drug. In this case, the patient has not tried and failed 
the required drug(s). Our reviewer also found that there is no documentation provided indicating that the Plans 
required drug(s) would likely be less effective and/or likely have adverse effects 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the provider did not submit any 
additional pulmonary information including baseline arterial blood gas analysis (ABG), complete pulmonary 
function testing (PFT), polysomnography (PSG), or oximetry. The requested bi-level PAP therapy with backup 
rate in AVAPS mode is available on E0471 devices. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 1, 2021 to April 9, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says unauthorized, non-plan care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for medical services provided on April 1, 2021 to April 9, 2021 by 
an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Entyvio. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Stelara before they will approve the requested drug, Entyvio. In this case, there is no indication that the 
patient has tried and failed the required drug. Based on the medical records provided and the Medicare-
approved major drug compendia there is no indication that the plan's required drug would likely be less 
effective and/or likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara (J3358). 
 
You asked the Plan to pre-approve Stelara. You say that you are advocating that Stelara be a covered benefit 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not have any stated 
contraindications to the preferred products. The Plan also says that the enrollee has not tried any of the 
preferred agents. 
 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 Stelara. Our reviewer says that Stelara 
is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Avsola, 
Entyvio, or Remicade before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drug(s). Our reviewer also found that there is no documentation provided indicating that the 
plans required drug(s) would likely be less effective and/or likely have adverse effects 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 Stelara have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stelara (J3358).