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

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
requested SNF services are medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet Medicare criteria for coverage of the requested 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found this beneficiary 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that admission to a SNF is medically necessary. 
The Plan denied your request. The Plan says that you do not meet criteria because your doctor did not send 
medical records. 
 
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 Plan has provided absolutely no medical records in the case file 
submitted.  According to the case file, the provider from whom the Plan claims they tried to get records is a 
contract provider with the Plan.  Under Medicare rules, that means that these records are within the Plan's 
control and the Plan's failure to obtain those records should not be held against you. Therefore, we decided that 
the Plan has to pre-approve skilled nursing facility (SNF) admission.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
your dialysis treatments and you cannot afford to pay for these trips. The Plan denied your request. The Plan 
says you have exhausted your benefit and there is no coverage for transports beyond 20 per year. 
 
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 20 trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array (64555). 
 
You asked the Plan to pre-approve the outpatient service. You say that this procedure is medically necessary to 
alleviate the enrollee's pain to regain her maximum function. The Plan denied your request. The Plan says this 
procedure is unproven and not medically necessary due to insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient service have not been met. Therefore, we decided that the Plan does not have to pre-
approve the percutaneous implantation of neurostimulator electrode array (64555).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five additional home health aide (HHA) services. 
 
You asked the Plan to pre-approve the additional HHA services. You say that you continue to require these 
services. The Plan denied your request. The Plan says since you are no longer receiving skilled therapy in the 
home. HHA services cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional HHA services. Our 
reviewer says that the records do not support that the enrollee requires ongoing skilled care in the home, and as 
such, the requested HHA services cannot be covered. Our physician reviewer found the member is a 74-year-
old female with a medical history including congestive heart failure, chronic low back pain, diabetes mellitus 
and arthritis. She has been medically stable and does have any need for skilled care. She has a paid caregiver to assist with custodial needs.  
 
The documentation doesnt support that the member requires skilled nursing services or skilled rehab services 
to provide treatment that is medically necessary. The member does not require skilled nursing or rehab services 
to effectively provide treatment, care, and/or services in order to improve the members condition, perform a 
maintenance program to maintain the members condition and/or prevent deterioration.  The member has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  She has 
paid caregiver and does not require a home health assistant.  The requested home health services are not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional HHA services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve five additional home health aide (HHA) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for various home services (S9338, 99601, 99602). 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these services are not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes S9338, 99601, 99602 are not supported in the medical record. Specifically, these codes 
have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that these codes 
are not valid for Medicare purposes. 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 various home 
services (S9338, 99601, 99602).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
requested SNF services are medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet Medicare criteria for coverage of the 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require 
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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in a different setting, for example, home with home 
health, in residential care, or home with close follow-up with the doctor. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips to locations other than 
your primary care provider's office. 
 
You asked the Plan to provide additional routine transportation. You say that you are concerned about not 
having enough rides in your transportation benefit to get to your necessary therapy and other specialist 
appointments and to get to and from the fitness center to help your physical and mental health. The Plan denied 
your request. The Plan says your supplemental benefit covers a maximum of 30 trips per year to locations other 
than your primary care provider's office. Additional trips are not a covered 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 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request for additional trips exceeds the Plans maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to provide additional routine transportation 
trips to locations other than your primary care provider's office.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5212). 
 
You asked the Plan to pre-approve the lower denture. You say that this service is necessary. The Plan denied 
your request. The Plan says dentures are not covered by your dental 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 pre-approve a 
partial lower denture (D5212).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three additional direct skilled nursing services of a 
registered nurse (RN) (G0299 x3). 
 You asked the Plan to pre-approve the additional skilled nursing visits. You say that these visits are medically 
necessary, and you would like this claim to be reprocessed correctly. The Plan denied your request. The Plan 
says the records do not support the need for a skilled nurse to make more visits. 
 
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 skilled nursing visits. Our 
reviewer says that the additional skilled nursing visits are not medically reasonable and necessary for the 
enrollee. Our physician reviewer found there is no documentation that additional skilled nursing services are 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or 
to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
Our reviewer found that the records do not document any acute or unstable medical conditions or changes in 
medication or treatment which would necessitate any further skilled nursing visits beyond what have already 
been approved. Our physician reviewer also found that no medical notes from the enrollees treating physician 
are provided documenting an order or need for additional skilled nursing services. 
 
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 skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve three additional direct skilled nursing services of a registered nurse 
(RN) (G0299 x3).
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 SNF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical necessity rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that there is no documentation that you require 
skilled nursing services or skilled therapy services. 
 
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 heart and lung transplant with a device implantation 
(32853, 33945, 33979). 
 
You asked the Plan to pre-approve a heart and lung transplant with a device implantation. You say that this is 
medically necessary. The Plan denied your request. The Plan says an evaluation is more appropriate at this 
time. 
 
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 a heart and lung transplant with a 
device implantation. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found based on the complexity of the enrollee's cardiac 
condition, it would be premature to proceed with heart-lung transplantation at this time. Instead, a pre-
transplant evaluation is reasonable and prudent. 
 
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 heart and lung transplant with a device implantation have not been met. Therefore, we decided that the Plan does not have to pre-approve a heart and lung transplant with a device 
implantation (32853, 33945, 33979).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRA Abdomen w or w/o contrast (74185). 
 
You asked the Plan to pre-approve an MRA Abdomen w or w/o contrast (74185). You say that an MRA 
Abdomen w or w/o contrast is medically necessary. The Plan denied your request. The Plan says that the 
procedure does not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs 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 an MRA abdomen w or w/o contrast 
(74185). Our reviewer says that the requested MRA is medically necessary. Our physician reviewer found the 
enrollee has had an extensive workup coordinated by rheumatologists and the working diagnosis is giant cell 
arteritis. This disease is characterized by narrowing of the major arteries including aorta and its branches. MRA 
is the most diagnostic noninvasive way with which to analyze these arteries. In light of the clinical suspicion 
and the extensive workup by rheumatologists who are experts in this particular disease the requested MRA of 
the aorta should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA Abdomen w or w/o contrast (74185) have been met. Therefore, we 
decided that the Plan has to pre-approve an MRA Abdomen w or w/o contrast (74185).  
 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: 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 criteria for IRF care are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee suffered a fracture of the right hip for which surgery was performed. As 
of 4/6/2022, she required standby assistance for bed mobility and transfers and was able to maintain gait with a 
wheeled walker.  
 
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that 
the enrollee requires at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of therapy 
services. While the enrollee may be able to participate in and benefit from rehabilitation therapy, the 
documentation does not support that IRF services are medically reasonable and necessary 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vision services (99214, 66821) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve out-of-network vision care. You say that you saw this provider three years 
ago, and you are dissatisfied with the care you have received from network providers. The Plan denied your 
request. The Plan says out-of-network care is only covered in certain limited circumstances. The requested 
treatment is not urgent or emergent and can be performed by in-network providers. 
 
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 
vision services (99214, 66821) to be provided by an out-of-network (OON) provider.