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 for this patient. 
The Plan denied your request. The Plan says SNF care is not medically necessary and the patient can be 
managed at a lower level of 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 the patient has no skilled nursing needs.  
Although the patient has skilled therapy needs, they do not require them on a daily basis in an inpatient 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: 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 this is medically necessary. The Plan denied your 
request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a femur fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee 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 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: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0480) provided on January 22, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that you are in disagreement on the decision 
made where the claim denied due to missing prior authorization. You request reconsideration with the attached 
supporting documentation. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0480) provided on 
January 22, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) radiologic examination, 
spine, cervical (72040) provided August 4, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you sought chiropractic help to relieve 
your pain. Without an initial visit and x-rays, the problem could not be diagnosed or treated. The Plan denied 
your request. The Plan says this service is not covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99203) radiologic examination, spine, cervical 
(72040) provided August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional chiropractic visits. 
 
You asked the Plan to pre-approve additional chiropractic visits. You say that the requested additional 
chiropractic visits are medically necessary. The Plan denied your request. The Plan says the requested 
additional chiropractic visits do not meet 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 additional chiropractic visits. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found as of March 10, 2022, the enrollee had lower back pain, worse over the left 
SI joint than the right, due to sitting at the computer for extra time. The documentation is insufficient to support 
those 6 additional chiropractic visits are medically reasonable and necessary for the enrollee 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 additional chiropractic visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve six (6) additional chiropractic visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven (7) surgical teeth extractions (D7210) for tooth 
#20, #21, #23, #24, #25, #26 and #27. 
 
You asked the Plan to pre-approve teeth extractions. You say that the enrollee arrived at your office in severe 
pain. An exam and x-ray revealed that the enrollee had multiple infected teeth as well as multiple teeth with 
irreversible pulpitis. The enrollee has generalized moderate periodontal disease on her remaining dentition. 
You also say it is necessary to extract the remaining dentition and replace with a complete denture. This will 
eliminate the disease from her oral cavity and restore her chewing ability. The Plan denied your request. The 
Plan says the enrollees benefit has been exhausted for the 2022 plan year. 
 
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 three teeth 
extractions per calendar year.  
 
 
 
 We looked at the file and Medicare rules. The records show the enrollee was approved for three extractions for 
tooth #18, #28 and #29, on April 7, 2022, therefore, the enrollee has exhausted her maximum benefit for this 
service. Based on this information, we decided that the Plan's rules for coverage of teeth extractions have not 
been met. Therefore, we decided that the Plan does not have to pre-approve seven (7) surgical teeth extractions 
(D7210) for tooth #20, #21, #23, #24, #25, #26 and #27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Sensor for the enrollee. 
 
You asked the Plan to pre-approve this equipment. You say that this equipment is medically necessary for the 
enrollee. The Plan denied your request. The Plan says all of the required coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of this equipment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve this equipment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab services (81529) provided December 9, 2021. 
 
You asked the Plan to pre-approve the lab services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that molecular diagnostic tests used to assist in risk 
stratification of melanoma patients are covered when the beneficiary has stage T1b disease or higher. 
 
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 lab services. Our reviewer says that 
this service was not medically necessary. Our physician reviewer found the record shows the enrollee has T1A 
disease. 
 
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 lab services have been met. Therefore, we decided that the Plan does not 
have to pre-approve lab services (81529) provided December 9, 2021.
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. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 
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 
Injectafer is not medically reasonable and necessary in this case. Our physician reviewer found that based on 
the medical records provided the enrollee has not tried and failed the required drug(s). There is no indication 
that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently 
unstable for transfer to an LTACH. 
 
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 that in this case, the enrollee was admitted with acute hypoxic respiratory failure in 
the setting of chronic obstructive pulmonary disease. The record indicates that the enrollee continues to require high flow oxygen and other treatments and is noted to have persistent chest X-ray infiltrates and a rising 
leukocytosis. The record indicates that the enrollee is clinically not stable and requires oxygen acute care 
services. The enrollee continues to receive acute care services and these have not been denied. The medical 
record does not indicate that the enrollee requires services that he is not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is more appropriate for the 
patient than his current setting. The Plan denied your request. The Plan says the patient can continue to receive 
services in their current acute care hospital. 
 
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 patient appears to be more stable and improving with current care and should 
only require short-term additional acute care services that can be safely administered at the current facility until 
appropriate for a lower level of care. The patient does not require services at the LTACH that are not already 
available at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous. Transfer to a lower level of care may be considered when treatment has completed.  
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the ultraviolet light therapy provided on April 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that phototherapy is a standard of care for skin itching disorders such as prurigo nodularis. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the ultraviolet light therapy provided on April 21, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cervical/Thoracic Interlaminar Epidural (back 
injection). 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat injection can be considered when the 
first injection directly and significantly provided improvement of the condition being treated.  
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the cervical epidural steroid injection on 02/01/2022 provided 30 to 40 % pain relief for a couple of 
weeks. The review has determined that the requested second cervical interlaminar epidural steroid injection 
does not meet the Medicare LCD coverage criteria. 
 
 
 
 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Cervical/Thoracic Interlaminar Epidural (back injection).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the documentation does not support 
that it is medically reasonable and necessary to provide continued skilled therapy services on a daily basis. As a 
practical matter, you do not require the necessary services on 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve the implants. You say that you are not able to eat, are experiencing pain, and 
the dentures you have break easily. The Plan denied your request. The Plan says Medicare does not cover 
dental implants when teeth are present 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the implants 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the implants. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the limited dental 
documentation in the case file does not support that dental implants are medically reasonable and necessary for 
the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the implants have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental implants.