Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy with an out-of-network provider. You say that you want to 
see this provider. The Plan denied your request. The Plan says you must receive your care from a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided 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 implant supported crown on teeth 29 and 30 
(D6065), custom fabricated abutment on teeth 29 and 30 (D6057) 
and local anesthesia in conjunction with surgical procedures (D9215).  
You asked the Plan to pre-approve the implant supported crown, custom fabricated abutment and local 
anesthesia. You say that you would like reconsideration because the enrollee is waiting for the necessary 
treatment. The Plan denied your request. The Plan says the documentation submitted does not support the 
medical necessity of the requested dental services. 
 
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 implant 
supported crown, custom fabricated abutment and local anesthesia when the services are medically necessary 
and reasonable.  
 
We looked at your request, the file, and Medicare rules. Based on this information, we decided that the Plan's 
rules for coverage of the implant supported crown, custom fabricated abutment and local anesthesia have not 
been met. Specifically, the documentation submitted did not include any medical records to verify if the 
requested dental services are medically reasonable and necessary. Therefore, we decided that the Plan does not 
have to pre-approve the implant supported crown on teeth 29 and 30 (D6065), custom fabricated abutment on 
teeth 29 and 30 (D6057) 
and local anesthesia in conjunction with surgical procedures (D9215).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99283) provided on October 
22, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this visit was related to a 
complication of surgery and is included in the global surgical package and not separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for these 
procedures includes payment for complications following surgery.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit have not been met. Specifically, the documentation supports that 
this emergency department visit was directly related to a complication following surgery. Payment for this 
service is included in the global surgery package. Therefore, we decided that the Plan does not have to pay for 
the emergency department visit (99283) provided on October 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Visudyne. 
 
You asked the Plan to pre-approve Visudyne. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires 
a trial of Avastin before they will approve Visudyne. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Visudyne. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Visudyne. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drug of Avastin. The record does not show that 
this drug would likely be less effective and/or have adverse effects for the 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 Visudyne have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Visudyne.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is a safety issue, you are very imbalanced 
and can barely walk or stand. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that the SNF care is medically necessary. The Plan 
denied your request. The Plan says authorization denied because SNF care is not medically necessary, and the 
enrollee's needs can be met at lower level of care such as part time skilled services in long-term 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 that there are no identifiable skilled 
nursing service needs that require skilled nursing services, including the specialized skill, knowledge and 
judgment of a skilled professional nurse required to safely and effectively provide medically necessary and 
reasonable treatment. There are no identifiable skilled therapy service needs that require skilled therapy 
services, including the specialized skill, knowledge and judgment of a qualified therapist required to safely and 
effectively provide medically necessary and reasonable treatment. The enrollee does not require skilled nursing 
or therapy services on a daily basis. As a practical matter, the enrollee 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 care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like reconsideration 
because the pneumatic compression device is medically necessary. The Plan denied your request. The Plan says 
intermittent limb compression for the purpose of prevention of venous thromboembolismis a preventive 
service. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia service provided on February 11, 2020. 
 
You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because the Plan is the 
secondary payer for this enrollee so is not responsible for payment until after the primary payer has processed 
this claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed 
you to submit this claim to the enrollee's primary insurance carrier. As the secondary insurer, the Plan cannot 
be held responsible for anesthesia until the primary insurer has denied the claim for these services. Therefore, 
we decided that the Plan does not have to pay for anesthesia service provided on February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87150 and 87801) 
provided on November 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 87801 and 
87150 XU remains not supported. The place of service on the CMS-1500 form line 24B must reflect the 
location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results 
submitted indicate the specimen was collected on November 13, 2021, and received by the lab on November 
15, 2021. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 
87150 and 87801) provided on November 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis (bone growth) stimulator device to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve osteogenesis device. You say that the longer it takes for the enrollee to get 
this item, the longer recovery will take. The Plan denied your request. The Plan says the denial of authorization 
for this item is correct, because this provider is out-of-network with the Plan and the requested device can be 
provided by an in-network supplier. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an osteogenesis (bone growth) stimulator device to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
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 you need IRF care in order to get home and walking 
again. You say that you were abused in the last two nursing facilities you were in. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for coverage of IRF care. The Plan says that 
the enrollee can safely receive the services needed in other settings. 
 
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 for revision of a hip replacement surgery. The enrollee's 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the monitor is necessary due to 
hypoglycemia. The Plan denied your request. The Plan says the device is not medically necessary. 
 
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 does not indicate that the enrollee uses insulin 
with at least three daily injections or 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 requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose 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. The Plan denied your request. The Plan says you do not need an 
intensive team for 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 physician reviewer found 
that you were admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Your medical 
problems are stable. You do not require treatment by multiple therapies in an intensive rehabilitation therapy 
program. While you have a need for physical and/or occupational therapy, there is no documentation of a need 
for an intensive rehabilitation program. 
 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 interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested device. You say that you cannot walk because of chronic low 
back pain. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare. 
 
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 requested device. Our physician 
reviewer found that the Vertiflex spacer is experimental. More research is needed to show safety and efficacy. 
Therefore, the requested device is not considered 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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart catheterization and ventriculography. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee would be a candidate for a 
PCI of the right coronary artery. The Plan denied your request. The Plan says a second procedure is 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 the requested services. Our physician 
reviewer found that in this case, the enrollee underwent cardiac catheterization in April 2022, and has a right 
coronary artery lesion amenable to intervention. The record does not indicate the presence of any new 
symptoms or potential cardiac events.  The record indicates that the enrollee remains a candidate for right 
coronary intervention. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. 
 
 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 a heart catheterization and ventriculography.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee does not need treatments that can only be provided in the 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 physician 
reviewer found that the enrollee was admitted with atrial fibrillation and developed ischemic small bowel 
requiring operative intervention. The record indicates that he is improving but requires wound care and other 
acute care services. He continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that he is not currently receiving but that would be 
available at the LTACH facility. 
 
 
 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 long term acute care hospital (LTACH) services.