Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM. 
 
You asked the Plan to pre-approve a CGM. You say that the requested CGM is medically necessary. The Plan 
denied your request. The Plan says that the coverage criteria has not been 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 pre-approve a CGM. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the record indicates that you have 
diabetes. The records provided do not indicate that you are being treated with insulin or have problematic 
hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. 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 CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on November 23, 2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says payment is included in the 
global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery..  
 
We looked at the file and Medicare rules. Payment for the requested services (99204) is included in the global 
surgery payment for the procedure (11470) provided on November 24, 2022. Based on this information, we 
decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan 
does not have to pay for the office visit (99204) provided on November 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria. The Plan 
denied your request. The Plan says there are contracted providers within the network to provide this service. 
 
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 
IRF admission and services to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found the case file does not contain documentation of trial and failure of bilevel positive airway pressure (BiPAP) with backup rate and average volume-assured pressure support (AVAPS). The documentation is 
insufficient to support that a home ventilator (E0466) is medically reasonable and necessary in this case. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee's pain has been of long-
term duration, and they have failed non-operative treatment. You say that no other procedure ablates the nerve 
which is the source of the chronic low back pain, and this procedure is the only solution. The Plan denied your 
request. The Plan says medical studies have not proven this service is helpful for the treatment of the enrollee's 
health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows spinal stenosis and the cause of back 
pain 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.
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 based on the enrollee's current condition and 
functional deficits as well as their multiple comorbidities the services would meet the enrollee's care needs. The 
Plan denied your request. The Plan says the services the enrollee needs can be provided safely in another 
setting such as a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
 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 treatment by multiple therapies. The enrollee continues 
to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that they would meet criteria for admission to an acute inpatient 
rehabilitation facility. The enrollee can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says your medical record does not show that you require daily complex skilled 
nursing or skilled therapy in a SNF setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have documented skilled nursing or therapy needs. Daily skilled services 
are not shown to be required to establish a maintenance program or to prevent deterioration of your medical 
condition. The rules for coverage are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 want to go to rehabilitation in order to return 
home safely. The Plan denied your request. The Plan says the IRF care is not medically necessary, and your 
needs can be met at a lower level of care such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs do not require 
an acute rehab 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, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that you 
would meet criteria for admission to an acute inpatient rehabilitation 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120), interim 
retainer crown - further treatment or completion of diagnosis necessary prior to final impression (D6793 x2), 
interim pontic - further treatment or completion of diagnosis necessary prior to final impression (D6253 x3), 
and interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820). 
 
You asked the Plan to pre-approve The dental services represented by codes D9120, D6793, D6253 and 
D5820. The Plan denied your request. The Plan says the documentation provided does not meet the Plan's 
clinical criteria. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services represented by 
codes D9120, D6253 and D5820 are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve fixed partial denture sectioning (D9120), interim pontic - further 
treatment or completion of diagnosis necessary prior to final impression (D6253 x3), and interim partial 
denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820).  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services represented by code D6793 when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services represented by codes 
D6793. Our reviewer says that the documentation provided does not meet the criteria for coverage for 
provisional appliances for areas #'s 6 and 11. This procedure is beyond the scope of the plan. Our physician 
reviewer found the documentation indicates that a final treatment plan has not been made for the removal and 
replacement of the defective fixed bridge replacing missing teeth #'s 7, 8, 9 and 10. Provisional (temporary) 
replacements are not covered per the plan. These are normally included in the fee for the final appliances. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services represented by code D6793 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120), interim 
retainer crown - further treatment or completion of diagnosis necessary prior to final impression (D6793 x2), 
interim pontic - further treatment or completion of diagnosis necessary prior to final impression (D6253 x3), 
and interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820).
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 SNF care. You say that you need more therapy and nursing supervision 
before returning home. The Plan denied your request. The Plan says all the services you need are offered at the 
IRF, a transfer to SNF 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that you have complex functional impairments. Not 
all inpatient rehabilitation facility (IRF) goals have been met. The clinical documentation does not show that 
you require daily skilled services on an inpatient basis in a skilled nursing facility (since IRF goals haven't been 
met) thus not 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hospital bed, fixed height, with any type side rails, 
with mattress (E0250). 
 
You asked the Plan to pre-approve the hospital bed. You say that the enrollee really could benefit form a 
hospital bed and railings. The Plan denied your request. The Plan says the records do not support that the 
hospital bed is medically necessary 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed; or  
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 hospital bed. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is experiencing weakness that is impacting their ability to transfer and ambulate. 
However, the documentation does not indicate that the enrollee is unable to re-position themself while in bed or 
requires positioning of their body not feasible with an ordinary bed. There is limited information regarding the 
enrollees motor strength and level of function with regards to bed mobility, transfers, and ambulation. There is 
also no medical history or documentation indicating that the enrollee requires elevation of the head of the bed 
greater than 30 degrees. Therefore, the requested fixed height hospital bed (E0250) is not 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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the hospital bed, fixed height, with any type side rails, with mattress (E0250).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 14 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional 14 PT visits. You say that after your surgery you had a 
significant decrease in strength and increase in back pain and now walk with a cane and are afraid of falling. 
The Plan denied your request. The Plan says based on your current status, the request for care is more than 
needed to treat your problems. 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you have shown improvements in most areas of mobility, strength, 
and endurance. You have had extensive prior therapy approved and the documentation does not reveal that you 
require the ongoing unique skills of a professional therapist to safely and effectively provide treatment, or that 
the services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. 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 or deliver a program to maintain your 
current condition or to prevent or slow further deterioration. You are independent in a home exercise program. 
Ongoing professional skilled therapy is not medically necessary beyond what was already approved. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 14 physical therapy (PT) visits.
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 SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that you no longer require skilled nursing facility 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that you have had acute functional status change 
that would require assessment by skilled therapy and skilled nursing. Clinical documentation shows that 
inpatient skilled therapy goals have been met. There is no specific frequency of ongoing skilled nursing 
recommended, no recent medication changes or medical issues documented. The clinical documentation does 
not show that you require daily skilled services on an inpatient basis in a skilled nursing 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the requested drug is not indicated for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Synvisc. Our reviewer says that the 
requested for Synvisc is not medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee has a history of right hip pain due to osteoarthritis. The reviewer found that use of 
hyaluronic acid for the treatment of hip osteoarthritis is not recommend as positive evidence was limited by 
small sample sizes and inconsistent reporting. The reviewer found that the documentation does not support that 
the Synvisc is medically reasonable and necessary, nor safe and effective for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.