Persius/hicric huggingface dataset:
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria for SNF care. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. or documented skilled therapy needs.  You are ambulating more than 100 feet.  Daily skilled services are 
not required to establish a maintenance program or to prevent deterioration of your condition.  Your care needs, 
custodial and intermittent, can, as a practical matter, be provided 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the depression screening you received on November 12, 
2021. 
 
You asked the Plan to pay for the depression screening. You say that you had to switch to a new primary care 
doctor and the provider did the depression screening as part of you being established. The Plan denied your 
request. The Plan says you have exhausted your benefit for annual depression screening. 
 
The Plan must follow Medicare rules. Medicare rules say that only one depression screening is covered per 
year.  Records show that you already received a covered depression screening on July 20, 2021.  This one-per-
year restriction applies regardless of the reason for the service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the depression screening have not been met. Therefore, we decided that the Plan does not have to 
pay for the depression screening you received on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from January 6, 2020, to January 
17, 2020. 
 
You asked the Plan to pay for the medical services. You say that this claim should be paid. The Plan denied 
your request. The Plan says you did not timely file your claim for these services. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service.  
 
The record shows that a claim for the medical services was not filed until September 3, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for medical services provided from January 6, 2020, to January 17, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this does not meet the requirements for approval. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure (basivertebral nerve ablation) is experimental. More research is 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MTHFR genetic testing. 
 
You asked the Plan to pre-approve these services. You say that your sisters and daughter have been diagnosed 
with MTHFR and you should also be tested. The Plan denied your request. The Plan says the testing is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that MTHFR testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is MTHFR genetic testing. This testing is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve MTHFR genetic 
testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited exams (D0140), intraoral x-rays (D0220, D0230) 
and surgical extraction (D7210) provided on September 1, 2021, and September 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told you could be reimbursed for out-
of-network dental care. The Plan denied your request. The Plan says the providers in this case do not 
participate in Medicare, and therefore these services are not eligible for reimbursement. 
 
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 dental 
services when they are performed by a licensed dental provider who has not opted out of Original Medicare.  
 
 We looked at the file and the Plan's rules. The providers in this case have both chosen to opt-out of Medicare. 
Based on this information, we decided that the Plan's rules for coverage of the dental services have not been 
met. Therefore, we decided that the Plan does not have to pay for the limited exams (D0140), intraoral x-rays 
(D0220, D0230) and surgical extraction (D7210) provided on September 1, 2021, and September 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 50-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips. 
The Plan denied your request. The Plan says you have exhausted your transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules.  The Plan provided documentation showing that they have covered 50 routine transports. Based on this 
information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional trips for routine 
transportation beyond the Plan's 50-trip limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed. 
 
You asked the Plan to pre-approve a hospital bed. 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 follows Medicare rules. Medicare rules say that a fixed height hospital bed (E0250, E0251, E0290, 
E0291, and E0328) is covered if specific criteria are met. 
 
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 hospital bed. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found based on the medical records provided there 
is no documentation that the requested hospital bed meets Medicare criteria for medically necessary for you.  
 
 Provided records were reviewed; although the records report you have cancer, dementia and weakness the 
records do not clearly document that you require positioning of the body in ways not feasible with an ordinary 
bed or requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain or 
requires the head of the bed to be elevated more than 30 degrees most of the time due to problems with 
aspiration or requires traction equipment which can only be attached to a hospital bed. 
 
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 hospital bed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hospital bed.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the documentation supports that it is medically 
reasonable and necessary to provide these skilled nursing or skilled therapy services (or a combination of these 
services) on a daily basis on an inpatient basis, in a skilled nursing facility setting. However, the enrollee can 
receive the needed services in the current setting. The goal of an IRF stay is to enable a patient to return home 
safely or to a community-based environment upon discharge. A patient's treatment goals and achievements 
during an IRF admission are expected to reflect significant and timely progress toward this end result. All of 
the required services are offered at the 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 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: 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 you are currently in a nursing home and need to be in 
an IRF. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval 
of an IRF admission does not meet the requirements for approval. 
 
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 that you are medically stable, and you do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. At your current functional level, you will not be 
able to tolerate IRF level of therapies and are unlikely to make a significant functional recovery in the 7-10 
predicted period of time in an IRF. You do not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. An IRF 
admission is not medically necessary based on lack of medical complexity and lack of acute rehabilitation 
nursing needs. Your rehabilitation needs can be met at a lower intensity setting. The documentation does not 
support the necessity for admission to 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
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 power seat elevation system (E2300).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer. 
 
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 Injectafer. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has anemia of chronic kidney disease.  The requested medication is a new start.  The provided records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. 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.  The elements of the coverage criteria are not satisfied.  The requested service cannot be 
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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the enrollee's 
condition has greatly impacted his quality of life and has failed conservative approaches to treatment. You say 
that this treatment is considered safe and effective, and authorization should be approved. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 insertion of stabilization device 
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that there is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for the enrollees medical 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 the insertion of stabilization device (22869) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) guidance for needle placement 
(eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation (procedure 
code 77012) provided to the enrollee on September 8, 2021. 
 
You asked the Plan to pay for the services. You say that the documentation supports the services as billed. The 
Plan denied your request. The Plan says the records do not support that the procedure or service was distinct or 
independent from other services performed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
procedure report describes a CT guided biopsy of the left lower lobe. The documentation does not include 
documentation of CT for another procedure; therefore, CPT 77012 would not be reported separately with a 
procedure code that includes imaging guidance. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for computed tomography (CT) guidance for needle placement (eg, biopsy, aspiration, injection, 
localization device), radiological supervision and interpretation (procedure code 77012) provided to the 
enrollee on September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says that you do not meet 
Medicare criteria for coverage of the IRF care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the your nursing, medical and rehabilitation needs require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The documentation supports that you requires at 
least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of therapy services. There is a 
reasonable expectation that this patient 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: 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. You say that you need therapy to get back your quality of life, 
and you are unable to care for yourself at home. The Plan denied your request. The Plan says you do not meet 
the criteria for SNF services. 
  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 you 
do not qualify for SNF coverage. Our physician reviewer found that you do not have documented skilled 
nursing or skilled therapy needs. Your needs can be provided 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 pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that you would like reconsideration because the 
requested SNF care is medically necessary. The Plan denied your request. The Plan says you do not meet 
criteria for the requested SNF care. 
 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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found your care needs appear to be custodial 
and, as a practical matter, can be provided 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Skilled Nursing Facility (SNF) care.