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

 
We decided that the Plan does not have to pre-approve transforaminal epidural steroid injections. 
You asked the Plan to pre-approve transforaminal epidural steroid injections. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because it is not considered medically reasonable and necessary to perform more than 2 epidural 
injections in a single setting. 
 
The Plan follows Medicare rules. Medicare rules state that transforaminal epidural steroid injections may be 
covered if certain 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 transforaminal epidural steroid 
injections. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested 
transforaminal epidurals beyond what the Plan already approved. Our physician reviewer found transforaminal 
epidural steroid injections involving a maximum of two levels in one spinal region are considered medically 
reasonable and necessary. Most conditions do not ordinarily require epidural steroid injection at 2 levels in one 
spinal region. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transforaminal epidural steroid injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transforaminal epidural steroid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from April 
25, 2022, forward. 
 
You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that the requested 
inpatient mental health care continues to be medically necessary. The Plan denied your request. The Plan says 
the criteria for continued coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 continuation of inpatient psychiatric 
care. Our reviewer says that the requested care is not medically reasonable and necessary. Our physician 
reviewer found that you are a 54-year-old male who was admitted to the acute inpatient psychiatric 
hospitalization on April 18, 2022 with Major Depressive Disorder, Recurrent, Severe without Psychotic 
Features. Based upon review the records provided it was not expected that you would improve in a reasonable 
period of time beyond the dates in question as you were not showing any dangerousness to self or others, 
auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of 
safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care beyond the dates in question as you did not have any 
suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. 
 
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 continuation of inpatient psychiatric care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from April 25, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intradialytic Parenteral Nutrition (IDPN) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the IDPN. You say that you would like reconsideration because the member 
cannot receive this vital nutritional therapy and clinical services from an in-network provider. The Plan denied your request. The Plan says these services can be provided in-network. 
 
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 
Intradialytic Parenteral Nutrition (IDPN) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that you no longer need to have a hospital stay but 
need a higher level of care. You say that you need SNF level of care as you are at risk of falling and likely 
returning to the hospital. The Plan denied your request. The Plan says no skilled needs were identified. 
  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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that daily 
skilled services are required and there is no documentation of significant decline in your functional status to 
necessitate daily inpatient skilled therapy services. Services in the home with home health care or in a long-
term care facility on a part time basis are more appropriate. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF 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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services 
you and/or your provider are requesting do not meet the requirements for approval. 
 
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 you appear to be improving and more stable and require only short-term 
additional acute care that can be safely completed at the current facility. You do not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that you 
require that are not already available and covered 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #6 to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve a crown. You say that a crown for tooth #6 is medically necessary. The Plan 
denied your request. The Plan says the tooth does not appear to have significant breakdown due to decay or 
trauma. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of a crown (D2750) for tooth #6 to be 
provided by an out-of-network provider have not been met. Legible dental x-rays were not provided. Therefore, 
we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #6 to be provided by an out-
of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0120, D0274, D4346, D0220, D0230) 
provided August 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
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. The enrollee's dental benefits do not cover services provided out-of-
network. Therefore, we decided that the Plan does not have to pay for dental services (D0120, D0274, D4346, 
D0220, D0230) provided August 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. The Plan denied your request. The Plan says the 
requested services are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the requested additional therapy is generally not accepted as 
specific and effective therapy for the patients condition beyond what was approved by the health plan. The 
records do not demonstrate that the unique skills of a professional therapist are required to safely and 
effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or 
by or under the supervision of a therapist. Our reviewer found that the patient can transition to an independent 
home exercise program that they have been instructed in. The requested services are not part of a maintenance 
program. Our physician reviewer also found that the specialized skill, knowledge and judgment of a qualified 
therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition 
or to prevent or slow further deterioration. 
 
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 PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extraction services. 
 
You asked the Plan to pre-approve additional dental extraction services. You say that you are in pain and need 
these dental services. The Plan denied your request. The Plan says although dental services are covered to 
prepare the mouth for radiation services, they are not covered following radiation services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 2 dental 
extraction services every year. 
 
We looked at the file and Medicare rules. Although dental extraction services are covered to prepare the mouth 
for radiation treatment, this is not the situation that these services are being requested under. In this case, the 
radiation services have already been provided. The Plan has agreed to coverage of 2 dental extractions per their 
contractual obligation. The additional dental extractions will not be covered. Based on this information, we 
decided that the Plan's rules for coverage of dental extraction services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve dental extraction services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on January 13, 
2021. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 
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 code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. 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 anesthesia 
services provided to the enrollee on January 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that the enrollee has dry eyes. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra.  
 
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic dental x-ray (D0330) you received on January 
27, 2022. 
 
You asked the Plan to pay for the panoramic dental x-ray. You say that the dental work you had in November 
of 2019 was not done properly, so you had to go to another dentist. You don't believe you should have to pay 
for this because your gums are sore. The Plan denied your request. The Plan says you were not eligible for 
coverage of another panoramic dental x-ray on January 27, 2022, because you already received a covered 
panoramic dental x-ray on November 13, 2019.  This service is only covered once every three years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's coverage rules say 
that code D0330 is only covered once every three years. Because you already received a covered panoramic x-
ray on November 13, 2019, you have exhausted that benefit until after November 13, 2022. 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 panoramic dental x-ray (D0330) you received on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that it has been recommended that 
the enrollee get permanent dentures, which will be more flexible, soft, and will not hurt the enrollee's gums. 
You also say that the enrollee cannot afford a second set of dentures. The Plan denied your request. The Plan 
says this benefit has been exhausted. The Plan also says that they contacted the dental provider who advised 
they were willing to assist the enrollee with their current set of dentures. 
 
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 enrollee is limited to 1 upper 
complete and 1 lower complete denture every 5 years. The record shows that the enrollee received a complete 
maxillary denture (D5110) on June 17, 2021 and the enrollee's maxillary denture benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on August 18, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. The Plan denied your request. The 
Plan says this service exceeds the maximum allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on May 6, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter insertion rendered on June 28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. The file shows that the enrollee received services from a physician in 
the same group practice for the date of service at issue that were approved by the Plan. The services at issue 
must be billed as though from a single physician. Therefore, we decided that the Plan does not have to pay for 
the catheter insertion rendered on June 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(CPT code 78452) and echocardiography (CPT code 93306). 
 
You asked the Plan to pre-approve the services. You say that the enrollee has been short of breath for the past 
few weeks, the enrollee is having pain in their chest, and the enrollee has been waiting two (2) weeks to have 
this done. You state the provider wants to rule out coronary artery disease (CAD). The Plan denied your 
request. The Plan says very little information was received about the enrollee's illness. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of myocardial perfusion imaging, 
tomographic (SPECT) (CPT code 78452) and echocardiography (CPT code 93306) have been met. There are 
no medical records provided to verify if the services are necessary. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (CPT code 78452) and 
echocardiography (CPT code 93306).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve chiropractic care. You say that this provider does a lot more with you and 
you feel better going to them. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-
network chiropractor. 
 
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 chiropractic care to be provided by an out-of-network (OON) provider.