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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap for 
patients that do not receive adequate pain relief from traditional conservative methods. You say that the 
enrollee has failed conservative treatment and the Intracept procedure is medically necessary. The Plan denied 
your request. The Plan says medical studies haven't proven this service is helpful for the treatment of the 
enrollee's health problem. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. 
 
 
  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 member's complex needs can only be 
met in LTACH. The Plan denied your request. The Plan says the request is not medically necessary, when the 
enrollee is ready to leave the hospital, they can safely receive this care in another setting, such as a Skilled 
Nursing Facility (SNF). 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is 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 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 pay for drugs or medications dispensed in-office for home use 
(D9630) provided on July 11, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you needed an emergency extraction and there 
were no in-network providers within a reasonable distance. The Plan denied your request. The Plan says 
according to your dental benefit, the requested medications are not covered under any circumstance.  
 
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 the drugs 
or medications dispensed in-office for home use (D9630) provided on July 11, 2022 by an out-of-network 
provider.
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 this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says at the time of the request, the enrollees status is critical. 
The enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical 
conditions that cannot be appropriately treated in the current hospital, and there are no issues for which 
LTACH may offer a therapeutic advantage. 
 
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 transfer to the LTACH is not medically necessary as the patient is not yet stable for 
transfer and as it would not be clinically advantageous at this time. Completion of treatment at the current 
facility is 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 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 reimburse payment for endodontic therapy and other dental services 
(D1999, D3320) provided on November 15, 2021 by an out-of-network provider. 
 
You asked the Plan to reimburse payment for the dental services. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to reimburse payment for endodontic therapy and other dental services (D1999, D3320) provided on November 
15, 2021 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the pontics (D6240), and white retainer crowns (D6740) for tooth 
#4, #5, #6, and #8. We decided that the Plan does not have to pre-approve the core buildup (D2950), addition to 
a crown (D2954) for tooth #4, #7, and #8.  
 
You asked the Plan to pre-approve the dental services. You say that the dental services are medically necessary. 
The Plan denied your request. The Plan says that the x-rays do not show a completed root canal in tooth #8 
which will lead to a poor long-term prognosis for the tooth. Since tooth #8 is part of the bridge of teeth the 
entire treatment would be at risk. Therefore, the denial for authorization for these services is correct. 
 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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the dental services partially meet the criteria. Our physician reviewer found that the documentation 
provided indicates that teeth #5 and #6 are missing. A fixed bridge replacing these missing teeth is reasonable 
and necessary. Therefore, the white retainer crowns (D6740) and the pontics (D6240) would meet the criteria 
for coverage. However, it does not appear the core buildup (D2950) on teeth #4 and #7 are necessary since the 
coronal structures appear intact. Tooth #8 does not appear to have a root canal; therefore, a post/core (D2954) 
is not required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have partially been met. 
 
We decided that the Plan has to pre-approve the pontics (D6240), and white retainer crowns (D6740) for 
tooth #4, #5, #6, and #8.  
 
 Therefore, we decided that the Plan has to pre-approve the pontics (D6240), and white retainer crowns 
(D6740) for tooth #4, #5, #6, and #8.  
 
We also decided that the Plan does not have to pre-approve the core buildup (D2950), addition to a 
crown (D2954) for tooth #4, #7, and #8. 
 
 Therefore, we decided that the Plan does not have to pre-approve the core buildup (D2950), addition to a 
crown (D2954) for tooth #4, #7, and #8. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on June 13, 2022.
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 it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met 
and the enrollee can safely receive the services they need at a skilled nursing facility (SNF). 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for lobectomy and pneumothorax and was discharged to a SNF on November 10, 2022. 
Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) system. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day CGM system. You say that you have been paying 
out of pocket for this device and the device is helpful. You would like help from the plan to pay for this item. 
The Plan denied your request. The Plan says you do not meet coverage criteria for approval of the requested 
CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 14-day CGM system have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14-day continuous glucose monitor (CGM) system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex superion device. 
 
You asked the Plan to pre-approve Vertiflex superion device. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 Vertiflex superion device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has spinal stenosis with neurogenic claudication and spondylosis with 
radiculopathy. The requested procedure is experimental. More research is needed. Therefore, the enrollee does 
not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Vertiflex superion device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of ILR. You say that this ILR is medically necessary and 
reasonable for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of 
the ILR 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 insertion of ILR. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at issue is the appropriateness and medical necessity of implanting an ILR in the clinical 
management of this patient. The patient had no history of atrial fibrillation, nor were any significant cardiac 
arrhythmias noted on electrocardiographic monitoring. A recent randomized clinical trial found that continuous 
monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial 
fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of implantable loop recorder (ILR).
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. The Plan denied your request. The Plan says the records do not 
show the enrollee's needs are complex and care can be given 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted seizures. Medical problems are stable.  There are no complex or nursing rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the evaluation and management services. You say that the in-network 
providers are much further than the provider that you would like to see. You say that the in-network providers 
are not able to see you until January 2023. You also say that you need to see this provider because of your 
diagnosis. The Plan denied your request. The Plan says there are network providers available to provide the 
requested services. The Plan also says that the requested services are not urgent or emergent in nature. 
 
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 confirmed there are 
network providers available who can provide the services at issue in this appeal. We found no exception that 
would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-
approve office visits to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71046) provided on June 2, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the chest x-ray. You say that authorization is not required for current procedural 
terminology (CPT) code 71046. You also say that you would like this claim to be reprocessed. The Plan denied 
your request. The Plan says this service was rendered by an OON provider, and the enrollee was not referred by 
their primary care provider. The Plan also says these services are not urgent or emergent, nor 
were they approved in advance. 
 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 chest x-ray (71046) provided on June 2, 2022, 
by an out-of-network (OON) provider.
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 is ready to be discharged to a SNF and 
continue the next level of care. You say that the enrollee would not be safe to discharge home with home health 
as they will need assistance and continued therapy. The Plan denied your request. The Plan says the SNF 
services you are requesting do not meet the requirements for approval. 
 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 the medical records do not document the need for daily inpatient skilled nursing 
services. There is documentation that on-going daily skilled therapy services are required. Provided records 
document the enrollee is still very limited functionally, with a significant decline in their functional status 
compared to their baseline. The health plan has indicated that continued care in the acute rehabilitation hospital 
will be covered as is medically warranted until the enrollee is stable to transfer to 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 SNF care.