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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that the coverage 
criteria for admission to a SNF has not been met. 
 
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. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have documented skilled nursing or skilled therapy needs. Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
your condition. 
 
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 pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix blood glucose test strips. 
 
You asked the Plan to pre-approve True Metrix blood glucose test strips. You say that the requested test strips 
are medically necessary. The Plan denied your request. The Plan says True Metrix blood glucose testing strips 
are not a preferred product with the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may limit coverage of the DME to only 
preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. The requested brand of test strips being requested are not provided by 
a preferred manufacturer. The records do not demonstrate that there is a medical reason why the Plan's 
preferred brand of test strips would not suffice. Based on this information, we decided that Medicare rules for 
coverage of True Metrix blood glucose test strips have not been met. Therefore, we decided that the Plan does 
not have to pre-approve True Metrix blood glucose test strips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), abdomen and pelvis; 
without contrast material (74176). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis, without contrast. You say that the 
enrollee needs a CT scan. The Plan denied your request. The Plan says necessary blood tests have not been 
performed prior to requesting the CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the abdomen and pelvis, 
without contrast. Our reviewer says that a CT scan is not medically necessary. Our physician reviewer found 
that this enrollee has markedly increased liver function tests. Ultrasound of the right upper quadrant was 
negative. CT of the abdomen and pelvis without and with contrast would be the next indicated procedure but 
the enrollee is allergic to contrast; unknown type of allergic reaction. The usefulness of CT without intravenous 
(IV) contrast would be limited in the evaluation of the liver. The referring physician has indicated the order for 
the CT could be changed if more appropriate to MRI. Thus, the CT scan without contrast is 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 a CT scan of the abdomen and pelvis, without contrast have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT), abdomen and 
pelvis; without contrast material (74176).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Echocardiography, transesophageal, real-time with image 
documentation (2D) (with or without M-mode recording) (99312) provided June 8, 2022. 
 
You asked the Plan to pay for the outpatient procedure. You say that please review the documentation to 
support the charges. The Plan denied your request. The Plan says procedure code 93312 has not met the 
associated Diagnosis Code relationship criteria for CMS ID(s) L33579. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99312 is echocardiography, transesophageal, real-time 
with image documentation (2d) (with or without m-mode recording); including probe placement, image 
acquisition, interpretation and report. 
 
We find that CPT code 99312 is not supported in the medical record. Specifically, the claim was submitted 
with the diagnosis codes I25.10, Z95.1, Z95.3, Z86.718, Z86.73, Z87.891 and Z79.01, none of which met the 
associated diagnosis code relationship criteria. A corrected claim is needed to process the claim. Based on this 
information, we decided that Medicare rules for coverage of the outpatient procedure have not been met. 
Therefore, we decided that the Plan does not have to pay for Echocardiography, transesophageal, real-time with 
image documentation (2D) (with or without M-mode recording) (99312) provided June 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request 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. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that daily skilled services are not required. There is no documentation that the 
enrollee requires services on an inpatient basis, only in a skilled nursing facility setting. Records support that 
services in the home with home health care or in a long-term care facility on a part time basis are 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, 
femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the 
same vessel, when performed (37226), and revascularization, endovascular, open or percutaneous, tibial, 
peroneal artery, unilateral, initial vessel; with transluminal angioplasty (37228). 
 
You asked the Plan to pre-approve revascularization services. You say that this is medically necessary for the 
enrollee. 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 revascularization services. Our 
reviewer says that the requested revascularization services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found while the enrollee has a history of peripheral vascular 
disease, the documentation does not confirm the presence of severe disease. The reviewer found the 
documentation does not indicate there has been a trial of medical therapy. Therefore, the reviewer found that 
the requested services are 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 revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, femoral, popliteal 
artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when 
performed (37226), and revascularization, endovascular, open or percutaneous, tibial, peroneal artery, 
unilateral, initial vessel; with transluminal angioplasty (37228).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device and segmental gradient 
pressure pneumatic appliance provided on March 2, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and segmental gradient pressure pneumatic 
appliance. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
items rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device and segmental gradient pressure pneumatic appliance provided on 
March 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional physical therapy is medically 
necessary for this enrollee. The Plan denied your request. The Plan says the requested therapy is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the record indicates that the enrollee has received 24 visits for 
aftercare following joint replacement surgery. The record indicates that the additional visits are for low back 
pain. The record indicates that the enrollee had good results from injections. The records provided are 
insufficient to establish that the services requested require the skills of a therapist are needed to treat the illness 
or injury. The elements of the coverage criteria are not satisfied; the requested services are not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve six (6) additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D6068 and D6056). 
 
You asked the Plan to pre-approve the dental services (D6068 and D6056). You say that the services requested 
are medically necessary. The Plan denied your request. The Plan says the dental services (D6068 and D6056) 
are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 the 
dental services (D6068 and D6056).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (J7237). 
 
You asked the Plan to pre-approve Monovisc. You say that you need this immediately. You also say that you 
do not understand why it is being denied. The Plan denied your request. The Plan says you have not tried and 
failed the preferred drugs, Orthovisc, Synvisc, or Synvisc-One. 
 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 Monovisc. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred drugs. The reviewer found that the record does not indicate 
that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternative. Therefore, the reviewer found that the step therapy criteria have not been 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc (J7237).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted procedure, for dentoalveolar structures 
(41899) and the bone debridement (11044). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule.  
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the unlisted procedure, 
for dentoalveolar structures (41899) and the bone debridement (11044).
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 has chronic low back pain 
and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has multi-level 
degenerative disease including severe neuroforaminal stenosis at L4-L5 the level requested for treatment. The 
record does not indicate that the enrollee has undergone at least 6 months of non-operative treatment since the 
chronic condition has worsened. The record does not document that the enrollee is not indicated for operative 
intervention at no more than two levels. The services are therefore not reasonable or 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740), first intraoral periapical x-ray (D0220), 
periodic oral evaluation (D0120), prophylaxis (D1110), amalgam (D2150), and resin-based composites (codes 
D2331, D2332, D2335, D2391, and D2391) provided from March 1, 2022, to May 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that this provider is a family friend. You also say 
that this provider does both crowns and implants, and not every dentist does both procedures. The Plan denied 
your request. The Plan says the dental services were received from an OON provider and are not covered by 
your supplemental benefits. 
 
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 record shows you received the requested dental services from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested items or services are not covered under this 
benefit when received from an OON provider. Therefore, we decided that the Plan does not have to pay for the 
crown (D2740), first intraoral periapical x-ray (D0220), periodic oral evaluation (D0120), prophylaxis 
(D1110), amalgam (D2150), and resin-based composites (codes D2331, D2332, D2335, D2391, and D2391) 
provided from March 1, 2022, to May 24, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided lumbar decompression services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is not in a clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that a percutaneous image-guided lumbar 
decompression is only covered under certain medical indications. 
 
We looked at the file and Medicare rules. The records provided do not show that the enrollee is in a Medicare 
approved clinical study.  Based on this information, we decided that Medicare rules for coverage of the 
requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve image-
guided lumbar decompression services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit (90832) provided on February 8, 2022. 
 
You asked the Plan to pay for a psychotherapy visit. You say that this is supported in the records. The Plan 
denied your request. The Plan says there is no documentation of a consultation with the enrollee's primary care 
physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a psychotherapy visit have not been met. Specifically, the record does not include documentation 
of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare 
rules. Therefore, we decided that the Plan does not have to pay for a psychotherapy visit (90832) provided on 
February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots (D2750) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements to be approved, Records sent by your dentist did not show these conditions. 
Please talk to your dentist about our decision. We used clinical policy ENVD.UM.CP.0024 Removal of 
Residual Tooth Roots to make this decision. 
 
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 do not 
meet the clinical requirements to be covered Therefore, we decided that the Plan does not have to pre-approve 
the removal of residual tooth roots (D2750)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the IRF admission criteria. You 
say the enrollee's ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says criteria for admission to the IRF have 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 the complexity of the enrollees nursing medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee 
may not be at their prior level of function and would benefit from additional occupational and physical therapy, 
but they do not require the intensity of therapies provided on acute inpatient rehabilitation. 
 
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 IRF admission and services.