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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the rehabilitation the enrollee is currently receiving is not helpful. 
 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 the enrollee 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 documentation does not 
reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The 
enrollee's functional level does not require skilled therapy services with  the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of 
these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary 
services on 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) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sacroiliac joint injection. 
 
You asked the Plan to pre-approve the sacroiliac joint injection. The Plan denied your request. The Plan says 
the injection 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 sacroiliac joint injection. 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 on physical examination of tenderness to the 
sacroiliac joint and no mention of sacroiliac provocative testing being completed with positive findings. The 
clinical value and effectiveness of sacroiliac joint injection in the absence of tenderness and negative 
provocative testing results have not been demonstrated in the peer-reviewed literature. 
 
  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 sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the sacroiliac joint injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 26, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74181 
is a column II code to column I code 74183. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral x-rays (D0230) provided on 
November 13, 2021. 
 
You asked the Plan to pay for additional intraoral x-rays. You say that you should not have to pay this bill, as 
you have a $1,000 annual allowance for dental care. The Plan denied your request. The Plan says there is a 
limit to the number of intraoral x-rays the Plan will cover each year. You received three on the date in question, 
and the Plan can cover one per year. The first intraoral x-ray has been covered and paid, but you are 
responsible for the additional images. 
 
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 
intraoral x-ray per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the intraoral x-rays are requested in a 
frequency that exceeds what is covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the additional intraoral x-rays (D0230) provided on November 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endovenous ablation therapy of incompetent vein 
(36482). 
 
You asked the Plan to pre-approve an endovenous ablation therapy of incompetent vein. You say that the 
requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical 
necessity rules for the requested service 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 endovenous ablation therapy of 
incompetent vein. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that there is insufficient documentation to support the 
medical necessity of the requested endovenous ablation therapy in the enrollees 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 an endovenous ablation therapy of incompetent vein have not been met. Therefore, we decided that the Plan does not have to pre-approve an endovenous ablation therapy of 
incompetent vein (36482).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grocery benefit. 
 
You asked the Plan to pre-approve a grocery benefit. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says you do not meet criteria for the grocery benefit. 
 
Medicare generally does not cover a grocery benefit. However, the Plan offers a grocery benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan's contract clearly 
states you must have a diagnosis of both diabetes and depression in order to be eligible for the grocery benefit. 
The file does not contain documentation showing that you meet this criterion. Therefore, we decided that the 
Plan does not have to pre-approve a grocery benefit.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
(A0998) provided on September 24, 2021. 
 
You asked the Plan to pay for the ambulance response without transport. You say that you fainted, and these 
services were necessary, but you were feeling better after evaluation and did not feel you needed to go to the 
emergency room. You have only had to pay $150 in the past for ambulance services, and you feel you should 
not be responsible for the whole bill in this case. The Plan denied your request. The Plan says the ambulance 
benefit is a transportation benefit. When no transportation is provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 24, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport (A0998) provided on September 24, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional routine transportation trips. 
 
You asked the Plan to pre-approve 20 additional routine transportation trips. You say that you need 
transportation to dialysis. The Plan denied your request. The Plan says you have utilized the maximum number 
of transportation trips allowed per year. 
 
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 20 trips per year.  
 
   
We looked at your request, the records in the case file, and the rules. 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 20 additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva plus test strips, a non-preferred 
brand. 
 
You asked the Plan to pre-approve Accu-Chek Aviva plus test strips, a non-preferred brand. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says non-preferred test 
strips are only approved if you have an insulin pump or if you have a medical condition requiring the use of a 
non-preferred meter. The records provided for review do not indicate that you have an insulin pump or a 
medical condition that prevents you from using a preferred glucose monitor and test strips. 
 
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members 
the benefits offered under the plan including applicable conditions and limitations. 
 
We looked at the file, the Plan's contract, and Medicare rules. The Plan's contract clearly says that non-
preferred test strips are only approved if you have an insulin pump or if you have a medical condition requiring 
the use of a non-preferred meter. The records provided for review do not indicate that you have an insulin 
pump or a medical condition that prevents you from using a preferred glucose monitor and test strips. 
Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva plus test strips, a non-
preferred brand.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on June 10, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that the admitting diagnosis is not related 
to the patient's stay. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the members terminal condition. The 
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of 
election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers 
attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for emergency room services provided on June 10, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice care provided in nursing long term care facility 
(Q5003) from September 17, 2021, through September 30, 2021. 
 
You asked the Plan to pay for hospice care provided in nursing long term care facility (Q5003). You say that  
The Plan denied your request. The Plan says the member was covered under Medicare's (CMS) hospice 
program from September 17, 2021, ending December 15, 2021. Hospice is responsible until the end of the 
month of hospice revocation. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospice care provided in nursing long term care facility 
(Q5003) from September 17, 2021, through September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of the sacroiliac joint (G0260). 
 
You asked the Plan to pre-approve an injection of the sacroiliac joint. You say that the requested service is a 
medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the 
requested service 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 injection of the sacroiliac joint. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the clinical value and effectiveness of a sacroiliac joint injection in the 
absence of tenderness and negative provocative testing results have not been demonstrated in the peer-reviewed 
literature. In this case, there is no documentation on physical examination of tenderness to the sacroiliac joint 
and no mention of sacroiliac provocative testing being completed with positive findings. 
 
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 injection of the sacroiliac joint have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an injection of the sacroiliac joint (G0260).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
tried simple analgesic or non-medication therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our physician reviewer found 
that the enrollee has a one-to-two-month history of right knee pain secondary to arthritis of the knee.  On exam 
there is a valgus deformity, effusion, and tenderness along the medial and lateral joint line with crepitus. Intra-
articular injections with hyaluronic acid are recommended as a possible option for severe osteoarthritis for 
patients who have not responded adequately to recommended conservative treatments. In this case, the records 
indicate the enrollee has not tried any ice, heat, muscle relaxants, chiropractic therapy, physical therapy, home 
exercise program, surgery, injections, bracing, or a Tens unit. A brace was ordered. The enrollee stated that she 
would not like to try cortisone injections. The review has determined that the documentation does not support 
that Euflexxa is medically reasonable or necessary 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day and Libre 2 Flash Glucose 
Monitoring System and Sensors. 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for 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 and does not 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 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
14-day and Libre 2 Flash Glucose Monitoring System and Sensors.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises provided on October 1, 2019. 
 
You asked the Plan to pay for the therapeutic exercises. You say that the claim could not be submitted within 
the required time because patients completed and updated information was not received in time. The Plan 
denied your request. The Plan says Medicare denies a claim if it is not received by the plan within 12 months or 
1 calendar year from the date when the services were rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the therapeutic exercises was not filed until December 10, 2021. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for therapeutic exercises provided on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed (E0301). 
 
You asked the Plan to pre-approve a heavy duty, extra wide hospital bed (E0301). You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the 
requested heavy duty, extra wide hospital bed (E0301). 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered 
if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more 
than 350 pounds but does not exceed 600 pounds.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hospital bed have not been met. Specifically, the record does not indicate that you weigh more 
than 350lbs. Therefore, we decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital 
bed (E0301).