Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial. The Plan denied 
your request. The Plan says a tertiary provider or out of network providers are not approved when the services 
can be done safely with an in-network. The services asked for do not need higher level of care. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair, with a patient 
weight capacity of 301 to 450 pounds (K0862) and additional wheelchair items and accessories (codes E2377, 
E2313, K0108, E1028, E2621, E0973, E0953, E1012, E2311, E2363, E2623, E1007, and E0955). 
 
You asked the Plan to pre-approve a group 3 heavy duty power wheelchair and additional wheelchair items and 
accessories. You say that your weight is over the weight capacity for my current power chair, leading to 
potential injury or other harm. The Plan denied your request. The Plan says your weight is less than minimum 
for which the requested for group 3 power wheelchair is covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 
95% of the weight capacity of the next lower weight class PWC. Medicare rules also say if the base PWC is not 
covered, then related accessories will be denied. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 3 heavy duty power wheelchair and additional wheelchair items and accessories have not 
been met. Specifically, the provided records show that your most recent documented weight is below the 
required weight limit of 301 to 450 pounds for a group 3 heavy duty power wheelchair (K0862). Therefore, we 
decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair, with a patient 
weight capacity of 301 to 450 pounds (K0862) and additional wheelchair items and accessories (codes E2377, 
E2313, K0108, E1028, E2621, E0973, E0953, E1012, E2311, E2363, E2623, E1007, and E0955).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
(D6057 x6), surgical placement of implant body: endosteal implant (D6010 x6), abutment supported 
porcelain/ceramic crown (D6058 x2), overdenture  complete maxillary (D5863), and surgical access to an 
implant body (D6011 x8). 
 
You asked the Plan to pre-approve the dental services. You say that you are disappointed the Plan is not 
covering  the services regarding your implant as this is why you changed plans. The Plan denied your request. 
The Plan says your benefit for the dental services represented by codes D6057, D6010 and D6058 has already 
been exhausted. The Plan also says overdenture  complete maxillary D5863, and surgical access to an implant 
body D6011 are not covered under the Plans dental benefits. 
 
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, certain limitations apply. The record 
shows your benefit for the dental services represented by codes D6057, D6010 and D6058 was exhausted on 
the initial request. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated 
abutment  includes placement (D6057 x6), surgical placement of implant body: endosteal implant (D6010 x6), 
abutment supported porcelain/ceramic crown (D6058 x5), overdenture  complete maxillary (D5863), and 
surgical access to an implant body (D6011 x8).
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 cannot get the care needed if they go 
home. You say the enrollee needs intravenous antibiotics and two-person assistance. The Plan denied your 
request. The Plan says the SNF care is not medically necessary, and the enrollee's needs can be met in the 
current hospital setting. 
 
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 the enrollee does not have documented skilled nursing needs, having tentatively 
competed his intravenous (IV) antibiotics on April 21, 2023. The enrollee does not have documented skilled 
therapy needs, as he appears to require little assistance for functional mobility. The enrollees 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have no mobility, and intensive physical therapy 
has been recommended by the hospital team. The Plan denied your request. The Plan says the requested IRF 
services do 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 the clinical documentation shows that the enrollee has complex functional 
impairments; however, no active medical issues have been specified. Thus, the complexity of the enrollee's 
documented nursing, medical, and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
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 member's current physical and medical 
condition requires a SNF admission. The Plan denied your request. The Plan says the SNF services requested 
do not meet the requirements for approval. 
 
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 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 have identifiable 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. However, the enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis 
in a SNF setting. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient 
basis 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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a battery and charger. 
 
You asked the Plan to pre-approve a battery and charger. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says that that the requested battery and charger codes are not 
compatible with power wheelchairs. 
 
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 documentation showing that an inappropriate battery 
and charger were requested. Therefore, we decided that the Plan has to pre-approve a battery and charger.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 You asked the Plan to pre-approve Orthovisc. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Orthovisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has tried 
and failed Durolane, Euflexxa, and Gelsyn-3. The documentation does not support that Durolane, Euflexxa, 
and Gelsyn-3 would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc 850. 
 You asked the Plan to pre-approve Genvisc 850. 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. 
 
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 Genvisc 850. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found 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 Genvisc 850 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Genvisc 850.
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 clearly exceeds the criteria for the IRF 
care. The Plan denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's 
needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 enrollee has a past medical history of multiple comorbidities hospitalized for left 
femur fracture with other hospital complications. The clinical documentation shows that the enrollee has 
complex functional impairments. However, there are no active medical comorbidities have been specified. This 
means that the complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be 
expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the computed tomography (CT) thorax (71260) provided June 28, 2022 
 
You asked the Plan to pay for the CT scan. You say that the facility was paid for the actual test, and you are 
billing for the reading only. The Plan denied your request. The Plan says that this service was not authorized. 
 
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 71260, 26 is computed tomography (CT) scan of the thorax with contrast. 
 
We asked our coder 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 CT scan. Our reviewer says that the records support that 
the criteria for coverage has been met. Our reviewer found the enrollee had a computed tomography 
angiography (CTA) chest on June 28, 2022, to rule out pulmonary embolism due to the enrollee's history of 
pleuritic chest pain. The exam was medically appropriate and necessary per the enrollee's symptoms. The Plan 
has paid the technical component but has denied the professional component for interpretation. The fee for 
interpreting the exam should be paid to the radiologist who interpreted the exam and would have been separate 
from the facility fee for providing the images for interpretation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have been met. Therefore, we decided that the Plan has to pay for 
the computed tomography (CT) thorax (71260) provided June 28, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee failed conservative 
treatment without relief. You say that this procedure improves quality of life for patients suffering from 
vertebrogenic low back pain and this procedure is safe and effective. The Plan denied your request. The Plan 
says the requested procedure 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the notes show a concern for pain coming from spinal stenosis but there is no recent 
trial of physical therapy documented.  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SpaceOAR procedure. 
 
You asked the Plan to pre-approve SpaceOAR. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet inclusion criteria because the cancer is in a high-risk group. 
 
The Plan follows Medicare rules. Medicare rules state that procedures such as SpaceOAR are only covered 
under certain conditions. 
 
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 SpaceOAR. Our reviewer says that the 
enrollee does not meet criteria for SpaceOAR. Our physician reviewer found Medicare criteria are explicit in 
which risk groups are covered and also the need to use SpaceOAR when other techniques would be insufficient 
due to anatomic geometry precluding meeting normal tissue constraints, anticoagulant use, or comorbid 
conditions. There is no specific reason why other means of rectal sparing would be insufficient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SpaceOAR have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the SpaceOAR procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization with percutaneous angioplasty 
(PCI). 
 
You asked the Plan to pre-approve cardiac catheterization with PCI. 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 the PTA is covered when used under certain 
conditions. 
 
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 cardiac catheterization with PCI. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found it is not clear that a 
guideline-supported indication for cardiac catheterization with percutaneous angioplasty is present. As a result, 
at this time PCI would not be considered medically appropriate and necessary 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 cardiac catheterization with PCI have not been met. Therefore, we decided that 
the Plan does not have to pre-approve cardiac catheterization with percutaneous angioplasty (PCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99213) with an oncologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the OON provider has been providing you with 
follow-up treatments two to four times a year and you want to continue to be treated by this provider. The Plan 
denied your request. The Plan says you must receive your care from a network provider. The requested services 
are not urgent or emergent and can be performed with an in-network provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99213) with an oncologist to be provided by an out-of-network (OON) provider.