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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you live alone and cannot care for yourself 
at this time. You say that you need extensive physical therapy and occupational therapy to be functional and 
safe at home. The Plan denied your request. The Plan says the records do not show that the enrollee needs 
skilled services on a daily basis. 

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 the enrollee does not have 
documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee 
is ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision.  
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the 
enrollee's condition.  The enrollee's care needs, as a practical matter, can 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block injection. 
 
You asked the Plan to pre-approve genicular nerve block injection. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
considered experimental/investigational. 
 
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 genicular nerve block injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to 
knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery.

The review has determined that the genicular nerve blocks are considered experimental/investigational in 
nature. The requested blocks are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve block injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve block injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic exoskeletal leg with advanced knee, foot 
and ankle features to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the prosthetic leg. You say that the enrollee is in need of 2 new prosthetics 
to return to his daily activities. The Plan denied your request. The Plan says enrollee's 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 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 
a prosthetic exoskeletal leg with advanced knee, foot and ankle features 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 skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to ADLs with 
minimal supervision. The enrollee's care needs, as a practical matter, can 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
appears unable to participate in daily skilled therapy based on the records provided. 
 
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 skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the drug is not 
supported for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Durolane. Our physician reviewer 
found that the enrollee has osteoarthritis of the left hip. Viscosupplementation therapy is medically necessary 
for the treatment of osteoarthritis in the knee. It is considered experimental and investigational for indications 
such as chondromalacia patellae, facet joint arthropathy. The review indicates that the requested use of 
Durolane is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The documentation does 
not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 
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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 11. However, the records do not show that the specimen was collected in an office setting. This 
means that the claim was billed with the incorrect POS code. 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 the lab services provided on August 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided May 14, 2020 to May 17, 
2020. 
 
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with N39.0, defined as urinary tract infection. 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 inpatient services. Our reviewer says that the 
documentation does not support the DRG billed. Our physician reviewer found the enrollee was admitted with 
abdominal pain, nausea and anorexia. The white blood cell count was 130000 and lipase 3343. Urinary tract 
infection was documented throughout the medical record and was treated with Rocephin. The review 
documented that the urinalysis was abnormal; however, the enrollee did not have clinical findings of a urinary 
tract infection such as dysuria, frequency, urgency, hematuria, pubic pain, or costovertebral angle tenderness. 
The abdominal pain, nausea and anorexia was attributed to pancreatitis. The elevated white blood cell count 
could also be attributed to the pancreatitis. Although the urine culture reported greater than 100,000 CFU/ml of 
4 morphotypes, this was likely suggestive of contamination. The review has determined that the documentation 
did not support the DRG code billed (N39.0 urinary tract infection).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided May 14, 2020 to May 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the enteral formula, nutritionally complete with intact 
nutrients (B4150). 
 
You asked the Plan to pre-approve the enteral formula. You say that the enrollee's feeding tube was removed 
7/20/2021 and now she is no longer receiving that nutrition, so this Ensure is very important. She is not a 
healthy weight and does not eat much solid food. The Plan denied your request. The Plan says nutrition 
products that are administered orally and related supplies are non-covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve the enteral formula, nutritionally complete with intact nutrients (B4150).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, you do not meet criteria for acute inpatient mental health treatment as you were not 
shown to be a danger to yourself or others. You had mild paranoia and mild internal preoccupation. You are 
noted to be cooperative and compliant with treatment while not showing any aggressive behaviors as you 
awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
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 trips. You say that you need a few more wheelchair vehicle rides. 
You also say that you are unable to walk down the stairs. The Plan denied your request. The Plan says 24 one-
way trips are covered every year. The Plan also says that the benefit has been exhausted. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants (D6010) for teeth # 3 and 14, and custom 
abutments (D6057) for teeth # 3 and 14. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services to be covered. You 
also say that your teeth have disintegrated due to medications that you have been taking. The Plan denied your 
request. The Plan says implants and custom abutments are covered once every 5 calendar years, per patient, per 
tooth. The Plan also says that the frequency limits have been reached. 
 
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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. Specifically, the frequency limits have been reached. The 
record shows that the Plan paid for implants and custom abutments for teeth # 3 and 14 that you received on 
September 2, 2021. Therefore, we decided that the Plan does not have to pre-approve implants (D6010) for 
teeth # 3 and 14, and custom abutments (D6057) for teeth # 3 and 14.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on December 30, 2019.

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim should be processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.

The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four extractions (D7140 x4) provided on June 28, 2021.

You asked the Plan to pay for the extractions. You say that you feel this work was needed for medical rather than cosmetic reasons. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the four extractions (D7140 x4) provided on June 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a swim spa. 
 
You asked the Plan to pre-approve a swim spa. You say that you are on disability and waiting on your 
motorized wheelchair. You say that the doctor recommended this for daily use. The Plan denied your request. 
The Plan says the swim spa does not meet the definition of durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a swim spa.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis services (20610) 
provided from April 7, 2021, to May 6, 2021. 
 
You asked the Plan to waive the copayment for the arthrocentesis services. You say that you would like these 
cost shares waived. The Plan denied your request. The Plan says the claims have processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $500 
deductible and $250 copayment for Medicare-covered surgery services.  
 
You have been asked to pay a total cost share of $483.56 for the arthrocentesis services ($251.34 cost share + 
$232.22 deductible. This service falls within the Medicare-covered surgery services benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the arthrocentesis services (20610) provided from April 7, 
2021, to May 6, 2021.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been 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 complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
There is not a reasonable expectation that you 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.