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

 
We decided that the Plan does not have to pre-approve parathyroid imaging studies to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve parathyroid imaging studies to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says you have no urgent or emergent need, and you are not 
receiving dialysis for you to obtain medical services out-of-network when there are in-network providers 
available. 
 
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 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 
parathyroid imaging studies to be provided by the requested out-of-network provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intrathecal Pump Implantation. 
 
You asked the Plan to pre-approve the Intrathecal Pump Implantation. You say that you would like 
reconsideration because the requested pump is medically necessary. The Plan denied your request. The Plan 
says you do 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 pre-approve the Intrathecal Pump Implantation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation of IT pump trial being completed, no percentage 
of relief, degree of side effects (including effects on ADL's), or patient acceptance provided.  The psychiatric 
evaluation does not provide clearance for IT pain pump, which indicates you have a history of missing 
appointments and failing to follow-up with treatment recommendations.  You admit to taking more medication 
than prescribed in the past; you report minimal knowledge of the IT device process.  The records do not 
indicate that you would not respond adequately to non-invasive methods of pain control, such as systemic 
opioids.  There has not been a preliminary trial of intraspinal opioid drug administration. 
 
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 Intrathecal Pump Implantation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Intrathecal Pump Implantation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 4 power wheelchair with accessories. (K0884, 
E2300, E2363, E1007, E2620, E1012, E0944, E1028, E0953, K0108, E2373, E2377, E2313, E2323, E0950, 
E0956, E2624, E0960). 
 
You asked the Plan to pre-approve the group 4 power wheelchair with accessories. You say that the power 
chair is medically necessary. The Plan denied your request. The Plan says this type of power wheelchair is non-
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that group 4 power wheelchairs have added 
capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided, they will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The type of power wheelchair requested is not covered under 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of the group 4 power 
wheelchair with accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 4 power wheelchair with accessories. (K0884, E2300, E2363, E1007, E2620, E1012, E0944, 
E1028, E0953, K0108, E2373, E2377, E2313, E2323, E0950, E0956, E2624, E0960).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is a lack of clinical and support notes. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan.  
 The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture with a flexible base (D5226). 
 
You asked the Plan to pre-approve the partial denture. You say that you lost the denture you got last year and 
need a replacement. The Plan denied your request. The Plan says you previously received a partial lower 
denture on March 2, 2021. This service is covered once every five years. 
 
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 can cover one lower 
partial denture  flexible base (D5226) every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the denture is requested in a frequency 
that is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial 
lower denture with a flexible base (D5226).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that you would like reconsideration because the SNF 
care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
coverage of SNF 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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Skilled Nursing Facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14 day reader (K0553). 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the member is not insulin treated multiple times a day. 
 
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 and requires 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 the Freestyle 
Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 
14 day reader (K0553).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the 12 additional PT visits. You say that you would like reconsideration 
because the requested PT is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet Medicare criteria for coverage of the requested PT. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the 12 additional PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the enrollee has had ample instruction and time to 
transition to a home exercise program. The therapy appears repetitive and he does not require a skilled 
professional therapist for ongoing therapy visits. The requested services are not part of a maintenance program 
and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 12 additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that you need this for 
your mental and physical health. The Plan denied your request. The Plan says you currently have a mattress. 
 
The Plan must follow Medicare rules. Medicare rules say that a group 2 support surface, such as a powered 
pressure-reducing air mattress, is covered if the beneficiary has multiple ulcers or a myocutaneous flap or skin 
graft.  
 
We looked at the file and Medicare rules. The submitted records do not show that you have multiple ulcers or a 
myocutaneous flap or skin graft. Based on this information, we decided that Medicare rules for coverage of a 
powered pressure-reducing air mattress have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a powered pressure-reducing air mattress (E0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) supplies 
(K0553). 
 
You asked the Plan to pre-approve the CGM supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says there is no evidence that the member is taking insulin injections three or 
more times a day with frequent adjustments to insulin. 
 
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 and requires 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 the CGM 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous 
glucose monitor (CGM) supplies (K0553).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for coverage of the SNF services. 
 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 this beneficiary does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) services.
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 admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity 
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick urine collection system. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
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.  
 
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 urine collection 
system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
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 the SNF care. You say that you would like reconsideration because the SNF 
care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
coverage of the SNF 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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the 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: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after February 
28, 2022. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that the 
documentation shows you have not made any improvements with therapy between March 11, 2022, and March 
24, 2022. The Plan also says that you do not have medical conditions that require daily assistance and 
supervision by a nurse, and your care and therapy can be safely managed at home with home health. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before February 28, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after February 28, 2022.  
 
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.