Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is still in the hospital and needs the 
approval for inpatient rehab before they can release her. They are notable to go home and care for themself at 
this time. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you 
are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the leg. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found there is left knee degenerative joint disease and the 
presence of an effusion visible on the x-ray. This provides a valid and accepted indication for the requested 
MRI left knee. Therefore, the MRI is medically 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of the leg.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided by an out-of-
network provider on November 29, 2022. You asked the Plan to pay for the CGM. You say that the enrollee should be covered for the CGM. The Plan 
denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM. Our reviewer says that the CGM 
coverage criteria was not met. Our physician reviewer found that the record indicates that the enrollee has 
diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has problematic 
hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are not satisfied. The 
requested service is not 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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pay for a continuous glucose monitor (CGM) provided by an out-of-network provider on November 29, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on April 19, 
2023, to June 14, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the SNF care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services.  
Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on 
April 19, 2023, to June 14, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on May 30, 
2023. 
 
You asked the Plan to pay for ambulance treatment without transport provided on May 30, 2023.. You say that 
you fell in the garage and received treatment but refused to go to the hospital. The Plan denied your request. 
The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport 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 May 30, 2023. 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 ambulance treatment without transport provided 
on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve more for a maxillary and mandibular  partial dentures  
resin base (including, retentive/clasping materials, rests, and teeth) (D5211) and (D5212). 
 
You asked the Plan to pre-approve more for the maxillary and mandibular partial dentures. You say that the 
state of your teeth is adversely affecting your wellbeing. You also say that you have submitted a picture of your 
mouth showing the state of your teeth. The Plan denied your request. The Plan says you will have reached the 
total amount the plan will pay in a year. 
 
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, certain limitations apply. The record 
shows that your yearly dental allowance reached $319.00 after claim numbers ending in 57465 (date of service 
February 12, 2023) and 16768 (date of service June 6, 2023) processed, leaving you with an available balance 
of $681.00 ($1,000.00 - $319.00 = $681.00). Based on these findings, you would be responsible for any 
remaining costs regarding procedure codes D5211 and D5212. Therefore, we decided that the Plan does not 
have to pre-approve more for a maxillary and mandibular  partial dentures  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5211) and (D5212).
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. You say that the enrollee's continued clinical 
complexity, need for both medical management in a hospital level of care, as well as therapy at a LTACH to 
optimize recovery.  The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
acute care and does not require transfer to a Long-Term Acute Care 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 is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time.  
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external mobile cardiovascular telemetry provided on 
April 4, 2023, by an OON provider.  
 
You asked the Plan to pay for the external mobile cardiovascular telemetry. You say that you are appealing the 
denial with supporting documentation. The Plan denied your request. The Plan says the service was not 
authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the external mobile cardiovascular telemetry 
provided on April 4, 2023, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 10, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you did not receive the enrollee's insurance 
information until May 2, 2023. The Plan denied your request. The Plan says the claim was not filed within the 
required timeframe. 
 
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 ambulance services was not filed until June 20, 2023. 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 ambulance services provided on April 10, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 You asked the Plan to pre-approve Orencia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Orencia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has rheumatoid arthritis. The documentation does not support that the enrollee has tried and 
failed Remicade, infliximab, Inflectra, or Simponi Aria, and Stelara. The documentation does not support that 
Remicade, infliximab, Inflectra, or Simponi Aria, and Stelara would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on July 1, 2022, to August 30, 
2022. 
 
You asked the Plan to pay for acupuncture services. You say that you meet all the requirements from the Plan. 
The Plan denied your request. The Plan says the requested services were not documented to be under 
appropriate supervision by a physician, nurse practitioner, or physician assistant who meets the requirements. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, nurse practitioner or physician assistant who has a 
masters or doctoral level degree in acupuncture and a current full, active, and unrestricted license to practice 
acupuncture in the state where care is being provided. Therefore, we decided that the Plan does not have to pay 
for acupuncture services provided on July 1, 2022, to August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for the water circulating heat pad with pump (E0217) 
billed for dates of service January 10, 2023, to January 31, 2023. 
 
You asked the Plan to pay for code E0217. You say that this item is medically necessary based on medical 
literature. 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 that water circulating heat pads with pumps 
(code E0217) are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0217 have not been met. Therefore, we decided that the Plan does not have to pay for to pay 
for the water circulating heat pad with pump (E0217) billed for dates of service January 10, 2023, to January 
31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing panel identified with code 81455. 
 
You asked the Plan to pre-approve genetic testing panel identified with code 81455. 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 follows Medicare rules. Medicare rules say that genetic testing panels are only covered for certain 
indications.  
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 genetic testing panel identified with 
code 81455. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of monoclonal 
gammopathy, with enlarged lymph nodes, unspecified. A computed tomography-guided lymph node biopsy on 
June 5, 2023, showed atypical lymphoid B cells. A bone marrow specimen collected on July 10, 2023, showed 
marrow involvement by kappa-restricted plasma cell myeloma with high-risk disease prognostic indicators. 
The enrollee does not have a documented diagnosis of recurrent, relapsed, refractory, metastatic, or advanced 
stage III or IV cancer. 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 genetic testing panel identified with code 81455 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve genetic testing panel identified with code 81455.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that records have been submitted to show medical 
necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the records show no notes from rehab and no 
follow-up visit after selective nerve root blocks scheduled to be done on August 31, 2023. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment and acupuncture 
provided on June 12, 2023, by an OON provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment and acupuncture. You say that you are 
appealing the denial with supporting documentation. The Plan denied your request. The Plan says the service 
was not authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment and 
acupuncture provided on June 12, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown 
(D6058), and prefabricated abutment  includes modification and placement (D6056) for tooth #4. 
 
You asked the Plan to pre-approve the dental services. You say that it is not your fault that the dental benefits 
were provided to you for implants on tooth 5 and tooth 12 on January 3, 2023. You also say that you need to 
have this procedure done for new implants placed on tooth 4. The Plan denied your request. The Plan says your 
benefit for the requested services has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on date of service January 3, 2023. Therefore, we 
decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown (D6058), 
and prefabricated abutment  includes modification and placement (D6056) for tooth #4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 110 additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional miles. You say that you have multiple doctors appointments 
and have exhausted the mileage restrictions per the plan rules. You also say that your appointments are outside 
of the 50 miles radius and you do not have any other means of transportation. The Plan denied your request. 
The Plan says you have exceeded your benefit limit. 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 84 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve an 
additional 110 additional trips for routine transportation. 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 110 additional routine transportation miles.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet evidence-based criteria. 
 
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 there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of back is not clear. 
 
   
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 (64628, 64629).