Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pre-diagnostic test (D0431) provided on January 11, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the enrollee should be covered for the dental 
services because you are an in-network provider. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the pre-diagnostic test is not covered by the Plan. 
 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 pay for the pre-
diagnostic test (D0431) provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided by a participating 
provider April 1, 2022. 
 
You asked the Plan to pay for an occlusal guard. You say that you thought that this would be covered. The Plan 
denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pay for an 
occlusal guard (D9944) provided by a participating provider on April 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the telephone evaluation not originating from a related evaluation and 
management (EM) service provided within the previous 7 days nor leading to an EM service or procedure 
within the next 24 hours or soonest available appointment (99441) provided on May 9, 2022. 
 
You asked the Plan to pay for the telehealth service. You say that this service was medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the enrollee received a subsequent telehealth visit 
with the 7-day period of the telehealth visit in this case. 
 
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. Specifically, the file does not support that the service in this case led to the 
enrollee's subsequent visit. Therefore, we decided that the Plan has to pay for the telephone evaluation not 
originating from a related evaluation and management (EM) service provided within the previous 7 days nor 
leading to an EM service or procedure within the next 24 hours or soonest available appointment (99441) 
provided on May 9, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 additional direct skilled nursing services of a 
registered nurse (RN). 
 
You asked the Plan to pre-approve the additional direct skilled nursing services of an RN. The Plan denied your 
request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 additional direct skilled nursing 
services of an RN. Our reviewer says that the requested services are not medically necessary or reasonable. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs. 
 
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 additional direct skilled nursing services of an RN have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 11 additional direct skilled nursing services 
of a registered nurse (RN).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the nerves innervating the 
sacroiliac joint. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered investigational and 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered an experimental/investigational procedure because of the wide variation in 
efficacy as described in the peer reviewed literature.  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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation of the nerves innervating the sacroiliac joint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that you would like this 
service to be reviewed for coverage. The Plan denied your request. The Plan says based on the provided 
information, this test is not medically necessary. 
 
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. 
Our reviewer says that a CT scan of the abdomen and pelvis is not reasonable and necessary for the enrollee. 
Our physician reviewer found the enrollee has anorexia, but their body mass index is 30. The enrollee has a 
history of multiple surgeries for renal stones and a stricture. Our reviewer found that there is mention of an 
abnormal esophagram, but no date or report. There is also a referral to gastrointestinal (GI) for 
esophagogastroduodenoscopy (EGD) but no information as to the status of this referral. Our physician reviewer 
also found that absent a GI evaluation and completion of the planned EGD, the medial necessity of the 
requested CT of the abdomen and pelvis has not been established in the submitted records. 
 
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 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation per site 
for tooth #6 and #11 (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that these procedures are needed for dental 
implants. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
plan. 
 
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 a 
bone replacement graft for ridge preservation per site for tooth #6 and #11 (D7953).
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 enrollee needs SNF care. The Plan denied your 
request. The Plan says the enrollee is not medically stable for transfer and does not meet the criteria for 
coverage. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 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 a mobile cardiac outpatient telemetry (MCOT) monitor. 
 
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 cardiac monitoring is covered when 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation to support 
that a significant cardiac arrhythmia is a likely cause of the enrollee's symptoms, or that the diagnosis of a 
significant cardiac arrhythmia as the cause of her symptoms could only be established with an MCOT monitor 
with real-time telemetry. There is no supportive evidence that the ordering practitioner documented that other 
outpatient electrocardiogram (ECG) monitoring had been negative. A 30-day ambulatory ECG monitor has not 
been performed. In summary, there is insufficient documentation to support the medical necessity for an 
MCOT monitor in this enrollees clinical management. 
 
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 mobile cardiac outpatient telemetry (MCOT) monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve StimQ peripheral nerve stimulation (PNS). 
 
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 PNS is covered when 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
The requested StimQ PNS is considered experimental/investigational in nature, as there is not enough proof of 
efficacy for the approach to treat low back pain. 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 StimQ peripheral nerve stimulation (PNS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 physician visits for wound care to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve 16 physician visits. You say that the requested services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider at issue in this case is not a network provider with the Plan. 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 16 physician visits. Our reviewer says that the requested 16 physician visits 
to be provided out-of-network are not medically necessary. Our physician reviewer found the provided 
documentation indicates that the facility staff changes the enrollee's dressings. The reviewer also found that the 
enrollee is mobile able to attend outpatient appointments. Therefore, the reviewer found that 16 out-of-network 
physician visits 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 16 physician visits have not been met.  
 
We found no exception that would require the Plan to pre-approve 16 physician visits. Therefore, we decided 
that the Plan does not have to pre-approve 16 physician visits for wound care to be provided by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has anemia of chronic 
kidney disease. He has not tried and failed the Plan's required drugs, Retacrit or Procrit. The records do not 
show that the required drugs would be contraindicated or less effective; therefore, Aranesp is 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 Aranesp.
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 you will be able to regain full mobility through an 
IRF. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and your needs 
can be met at a lower level of 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require rehabilitation nursing or treatment by multiple therapies. 
Although youve had a functional decline from you baseline level of function and would benefit from 
occupational and physical therapy, you do not require the intensity of therapies provided in 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires close observation 
and oxygen treatment. You say that the enrollee desperately needs acute care due to their current respiratory 
condition. The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and 
the enrollee can safely receive the care they need in another setting. 
 
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 they are currently receiving care. The enrollee is receiving appropriate care at the present 
acute care hospital. 
 
   
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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) (code 93306). 
 
You asked the Plan to pre-approve TTE. You say that a TTE is medically necessary. The Plan denied your 
request. The Plan says a TTE does not meet the Medicare coverage criteria. 
 
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 TTE. Our reviewer says that the 
requested TTE not considered medically reasonable and necessary in this case. Our physician reviewer found 
that at issue is the appropriateness and medical necessity of a repeat TTE, with negative radionuclide cardiac 
imaging in 2021 as well as TTE showing no significant valvular abnormalities. There have been no significant 
interim changes in exam or clinical condition. Clinical guidelines do not support carrying out a repeat TTE in 
this setting. In summary, there is no supportive evidence for the medical necessity of a TTE in this this 
patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transthoracic echocardiography (TTE) (code 93306).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 You asked the Plan to pre-approve insertion of an ILR. You say that the ILR is medically necessary for 
managing your condition. The Plan denied your request. The Plan says the criteria for the ILR have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related, but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 insertion of an ILR. Our reviewer says 
that the requested ILR is not medically reasonable and necessary. Our physician reviewer found that at issue is 
whether the requested authorization for placement of an ILR is medically appropriate and necessary. There is 
no history of an ambulatory electrocardiogram monitor having been performed to assess a possible arrhythmic 
etiology of syncope. In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ILR in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).