Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine dental visits to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the routine dental visits. You say that you do not want to change dentists 
because your current dentist knows everything about you. You also say that you have been going to this 
provider for a long time. The Plan denied your request. The Plan says going to an OON provider is not 
medically necessary because your needs can be met in-network. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve routine 
dental visits to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dentures (D5214 and D5213). 
 
You asked the Plan to pre-approve the dentures. You say that the services should be covered. The Plan denied 
your request. The Plan says these are not covered 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. 
 
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 the dentures (D5214 and D5213).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 10-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional rides to 
get to your treatments. The Plan denied your request. The Plan says you have exhausted your transportation 
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 10 trips per year.  
 We looked at your request, the records in the case file, and the rules. The Plan provided documentation 
showing that they have covered 10 routine transports. 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 trips for routine transportation beyond the Plan's 10-trip limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on August 17, 2021. 
 
You asked the Plan to pay for the ophthalmological services. You say that you were unaware that the provider 
was out-of-network. The Plan denied your request. The Plan says an eye exam out-of-network (POS) is not 
covered. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows the eye exam was provided by an out-of-network 
provider, which is not a covered vision benefit. Based on this information, we decided that the Plan's rules for 
coverage of the ophthalmological services have not been met. Therefore, we decided that the Plan does not 
have to pay for ophthalmological services provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CancerTYPEID testing (81540) provided on June 17, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the testing. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says non-urgent services should be rendered by 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 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 the CancerTYPEID testing (81540) provided on 
June 17, 2021 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) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires SNF care due to a diagnosis of 
Parkinson's disease.  You said that the enrollee cannot function on his own without assistance. The Plan denied 
your request. The Plan says the enrollee can be managed at a lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs.  The enrollee does not have documented skilled therapy needs.  Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition.  The 
enrollees care needs, custodial and intermittent, can, as a practical matter, 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 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: 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 SNF admission. You say that the enrollee requires inpatient therapy 
because he has not been able to make progress with outpatient treatment. The Plan denied your request. The 
Plan says the enrollee does not require daily skilled services. The request is custodial in nature. 
 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 admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found this patient does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely 
and effectively provide medically necessary and reasonable treatment in a SNF.  The patient does not have 
complex wound care or other SN need. The patient does not require skilled therapy services with the 
specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide 
medically necessary and reasonable treatment in a SNF.  It is not medically necessary and reasonable to 
provide skilled nursing or skilled therapy services on a daily basis in a SNF. This patient does not require SN or 
skilled therapy on an inpatient basis in a SNF.  
 
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 admission 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on September 30, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria 
for coverage. 
 
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 pay for the Guardant360 testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the use of surveillance for minimal residual disease is not currently a standard of care 
for early stage colon cancer. Use is not supported by the NCCN Guidelines. In addition, no stage is given 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 the Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on September 30, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that admission to a SNF 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 you 
qualify for SNF care. Our physician reviewer found you do not have documented skilled nursing needs but you 
do have documented skilled therapy needs.  You are just walking household distances.  Further strength and 
endurance training is reasonable, as you live alone.  Daily skilled services are required to establish a 
maintenance program or to prevent deterioration of your condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 IRF admission is medically necessary because you 
cannot walk and you don't have anyone at home to help with day-to-day activities. The Plan denied your 
request. The Plan says IRF care is not medically necessary and you can be managed at a lower level of care. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require or can tolerate this therapy on an intensive IRF level. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits you received from February 9, 2021, to 
November 3, 2021. 
 
You asked the Plan to pay for the office visits. You say that these should be covered because you couldn't find 
out what was causing your neuropathy, so you went to this provider. The Plan denied your request. The Plan 
says services provided by a provider who has opted-out of Medicare are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 
 
 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office 
visits you received from February 9, 2021, to November 3, 2021.
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 SNF services. You say that you need SNF services. The Plan denied your 
request. The Plan says you do not meet criteria for SNF coverage. 
 
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 you do not have documented skilled 
nursing needs or skilled therapy needs.  You are consistently ambulating more than 100 feet.  Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of your 
condition.  Your 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of heart monitor. 
 
You asked the Plan to pre-approve an insertion of heart monitor. 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 follows Medicare rules. Medicare rules say that electrocardiographic services are covered when 
specific 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 an insertion of heart monitor. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found at issue is the 
medical appropriateness and necessity of replacing his old implantable loop recorder (ILR) with a new ILR. 
The ILR is being requested to allow continued monitoring of his ventricular arrhythmias. Based on current 
guidelines and the documentation provided, there is insufficient clinical evidence to support the medical 
appropriateness and necessity of replacing the enrollees old ILR with a new ILR. 
 
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 insertion of heart monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion of heart monitor.
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 enrollee's condition requires intensive therapy. 
The Plan denied your request. The Plan says IRF criteria are not met in this case. 
 
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 is a female who was admitted on 3/9/22 with generalized weakness and 
altered mental status. She was found to be in septic shock with left pleural effusion. 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 patient's medical status does not require intensive 
physician and nursing oversight in an IRF. While the patient may benefit from additional multiple therapies, 
including physical and occupational therapy, the documentation does not reveal that the patient requires this 
therapy on an intensive IRF level or can tolerate an intensive therapy level given the patient's fatigue.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure remains experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the 
services you require can safely be received at a different setting, for example, home with home health, in 
residential care, or home with close follow-up with your 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there is no documentation that you require 
skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are 
not required to safely and effectively provide medically necessary and reasonable treatment. Records do not 
document the need for intravenous medications, new tube feeding, or ostomy care or daily complex wound 
care. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified 
therapist are required to safely and effectively provide medically necessary and reasonable treatment. There is 
no documentation that daily skilled services are required. Therapy notes document multiple occasions of 
inability to follow instructions and several occasions of refusal to participate with treatment. Part-time therapy 
services appear indicated based on your cognitive status and ability to participate. There is no documentation 
that you require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility 
on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick external catheter. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
The requested Purewick external catheter is considered incontinence supplies. While incontinence supplies may 
be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided 
that the Plan does not have to pre-approve a Purewick external catheter.