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

 
We decided that the Plan does not have to pay for laboratory services provided on June 13, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 laboratory services provided on June 13, 2022, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unlisted procedure on dentoalveolar structures 
(41899). 
 
You asked the Plan to pre-approve the unlisted procedure. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says that outpatient hospital services for dental procedures 
are not 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. Therefore, we decided that the Plan does not have to pre-approve an 
unlisted procedure on dentoalveolar structures (41899).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seat lift mechanism, electric (E0627) and miscellaneous 
DME supply, accessory, and/or service component (A9990). 
 
You asked the Plan to pre-approve power seat lift chair. You say that The lift chair is medically needed because 
you had back surgery and is not able to walk in a functional manner. You walk with a cane and cannot go up 
and down stairs. The Plan denied your request. The Plan says the requested power lift chair is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 power seat lift chair. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to Medicare, a seat lift mechanism is covered if an individual has severe arthritis of the hip or knee or has a severe neuromuscular disease. The seat lift mechanism must be a part of the 
treating practitioners course of treatment and be prescribed to effect improvement, or arrest or retard 
deterioration of the beneficiarys condition. Additionally, the beneficiary must be completely incapable of 
standing up from a regular armchair or any chair in their home. Once standing, the beneficiary must have the 
ability to ambulate. In this case, the documentation does not indicate that the enrollee has severe neuromuscular 
disease or that they are incapable of standing up from a regular armchair or any chair in their home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power seat lift chair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seat lift mechanism, electric (E0627) and miscellaneous DME supply, accessory, 
and/or service component (A9990).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a bilateral sclerotherapy treatment. 
 
You asked the Plan to pre-approve a bilateral sclerotherapy treatment. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that there is inadequate documentation of the vein size 
and no documentation of conservative treatment following the endovenous saphenous ablation. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments for symptomatic varicose tributaries 
are either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are greater than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 
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 a bilateral sclerotherapy treatment. Our 
reviewer says that the service is medically necessary and reasonable. Our physician reviewer found there is 
satisfactory documentation of persistent symptoms including stasis dermatitis that have persisted, despite 
conservative treatment, over 6 weeks following successful saphenous ablation.  The veins to be treated are 
documented to measure 4-5mm in diameter, meeting the criteria size requirement.  
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 bilateral sclerotherapy treatment have been met. Therefore, we decided that 
the Plan has to pre-approve a bilateral sclerotherapy treatment.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Darzalex. 
 
You asked the Plan to pre-approve Darzalex. You say that the requested drug is medically necessary for 
treatment of the enrollee's multiple myeloma. The Plan denied your request. The Plan says that use the 
requested drug is not reasonable and necessary because the enrollee has not had prior treatment of multiple 
myeloma. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Darzalex. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the use of this drug is supported by clinical 
research for patients like this, who have both liver and renal transplant and other comorbidities. The use of this 
drug is not listed as not indicated, not supported, or not recommended in any of the compendia. The 
documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary 
for this 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 Darzalex have been met. Therefore, we decided that the Plan has to pre-approve 
Darzalex.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
August 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim 
reviewed and granted appeal for payment. The Plan denied your request. The Plan says care received from 
OON providers will not be covered unless authorized. 
 
 
 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 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 the subsequent nursing facility care (99309) 
provided on August 25, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs more rehab for safety, 
strengthening and endurance. The Plan denied your request. The Plan says the request 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), of the chest, diagnostic; 
without contrast material (71250). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that in this case, the record 
indicates that the enrollee has shortness of breath secondary to grade 2 diastolic dysfunction. A CT angiogram 
of the chest demonstrated incidental atelectasis not deemed to be clinically significant. The enrollee also has 
sleep apnea with increasing symptoms and is undergoing evaluation with other testing. The record indicates 
that the requested test is being performed to demonstrate resolution of the atelectasis. The provided records do 
not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service at 
this time. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT), of the chest, diagnostic; without contrast material (71250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330), intraoral imaging (D0210), a 
2D oral image (D0250), and fluoride varnish (D1206), provided by a participating provider on June 27, 2022, 
to June 28, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not understand why you are being charged 
so much. The Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
panoramic imaging (D0330), intraoral imaging (D0210), a 2D oral image (D0250), and fluoride varnish 
(D1206), provided by a participating provider on June 27, 2022, to June 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally 
invasive, indirect visualization, with image guidance, includes obtaining bone graft when performed, and 
placement of transfixing device (27279). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee does meet medical criteria 
for surgery and there is imaging available. Reports are included. The Plan denied your request. The Plan says 
an SI joint injection is not reasonable or necessary 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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the LCD criteria requires prior SI joint injections to have had at least a 75% reduction 
in pain for the expected duration of the anesthetic used following and image-guided, contrast-enhanced SI joint 
injection on two separate occasions. This was not achieved. Therefore, the requested service is deemed not 
medically reasonable and 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive, indirect 
visualization, with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device (27279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair (A9270). 
 
You asked the Plan to pre-approve a recliner chair. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
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 recliner chair (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214), a comprehensive 
periodontal evaluation (D0180), an extraction of an erupted tooth (D7210) for teeth numbers 4 and 14, and a 
maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve a mandibular partial denture (D5214), a comprehensive periodontal 
evaluation (D0180), an extraction of an erupted tooth (D7210), and a maxillary partial denture (D5213). You 
say that you disagree with the denial for the requested services. The Plan denied your request. The Plan says 
the requested services is not a covered benefit. 
 
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 pre-approve a 
mandibular partial denture (D5214), a comprehensive periodontal evaluation (D0180), an extraction of an 
erupted tooth (D7210) for teeth numbers 4 and 14, and a maxillary partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve the requested services. You say that the treatment is medically necessary. 
The Plan denied your request. The Plan says non-facet pathology was not ruled out. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. She had transforaminal epidural steroid injections 
at L3-L4 and L5-S1. On physical exam she has a dysesthesia in the L3 and L4 distribution. There is no recent 
imaging which would rule out other pain generators. Therefore, at this time, the request is deemed not 
medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensors. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
device is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 We looked at the file and the rules. The requested sensors do not serve a purpose that is primarily medical in 
nature. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensors.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are non-weight bearing and cannot go home and 
take care of yourself. The Plan denied your request. The Plan says the criteria for admission to an IRF 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 do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You continue to 
have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that you would meet criteria for admission to an acute inpatient 
rehabilitation facility. You can receive further services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and skilled therapy on an inpatient basis in a 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 SNF care.