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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 28, 
2023 to June 26, 2023. 
 
You asked the Plan to pay for SNF care. You say that services which the enrollee required and received during 
the period in question are coverable. The Plan denied your request. The Plan says the enrollee did not have a 
need for a daily skilled nurse or therapist from June 5, 2023, to June 26, 2023. 
 
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 pay for 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 that there are no identifiable skilled therapy service needs. The enrollee did not 
require skilled nursing or therapy services on a daily basis. The enrollee did 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from May 28, 2023 to June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350), consultation-
diagnostic service rendered by a dentist or physician other than requesting dentist or physician (D9310), 
biologic materials to aid in soft and osseous tissue regeneration, per site (D4265), free soft tissue graft 
procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft 
(D4277), and a surgical sent (D5982) provided from November 9, 2022, through January 19, 2023. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the items/services at issue are not 
covered under the supplemental dental policy.  
  
 
 
 
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, the items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D 
oral/facial photographic image (D0350), consultation-diagnostic service rendered by a dentist or physician 
other than requesting dentist or physician (D9310), biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265), free soft tissue graft procedure (including recipient and donor surgical sites) 
first tooth, implant or edentulous tooth position in graft (D4277), and a surgical sent (D5982) provided from 
November 9, 2022, through January 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous tibial nerve stimulation. 
 
You asked the Plan to pre-approve percutaneous tibial nerve stimulation. You say that percutaneous tibial 
nerve stimulation is medically necessary. The Plan denied your request. The Plan says percutaneous tibial 
nerve stimulation 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 percutaneous tibial nerve stimulation. 
Our reviewer says that the requested percutaneous tibial nerve stimulation is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has an overactive bladder and 
urge incontinence. The enrollee has failed treatment with Gemtesa, Myrbetriq and Trospium. The enrollee also 
has progressive dementia, Parkinson's disease, and has had a stroke. Neuromodulation is indicated when incontinence is not related to a neurologic condition. In this case, the enrollee has multiple neurological 
conditions contributing to his incontinence. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous tibial nerve stimulation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous tibial nerve stimulation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services from the hospital to senior 
living facility rendered on June 22, 2023. 
 
You asked the Plan to pay for the services. You say that the hospital arranged the transport services. The Plan 
denied your request. The Plan says the enrollee's symptoms were not an emergency. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that after 
treatment, the enrollee was transported via ambulance from the hospital to the senior living facility. Vitals were 
stable and the enrollee was taken via stretcher. The enrollee didn't require treatment during transport. The 
documentation did not sufficiently support that other means of transport (such as stretcher van) were 
contraindicated for this enrollee on June 22, 2023. Also, the documentation does not support that the enrollee 
needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on June 22, 2023. The documentation does not support that the 
ambulance transport on June 22,2023 was medically reasonable and 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for non-emergent ambulance services from the hospital to senior living facility rendered on June 
22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an internal root repair of perforation defects tooth #29 
(D3333). 
 
You asked the Plan to pre-approve the internal root repair of perforation defects. You say that for a whole year 
you did not have any other work done. You also say that you have a nerve open and cannot sleep because it's 
very painful, annoying and it should be done immediately. The Plan denied your request. The Plan says this 
service is not covered in your dental benefit. 
 
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, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an internal 
root repair of perforation defects tooth #29 (D3333).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from July 1, 
2023, to July 30, 2023. 
 You asked the Plan to pay for SNF care. You say that the services should be covered under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not meet the criteria for the SNF stay. 
 
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 pay for 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 that there are no identifiable skilled nursing or skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the skilled nursing facility (SNF) stay provided from July 1, 2023, to July 30, 2023.
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 requested SNF services are necessary because 
you are short of breath when walking, you tire easily, you are weak, and lack endurance. The Plan denied your 
request. The Plan says the records provided do not show you need therapy or nursing services every day that 
must be given in a SNF. 
 
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 have chronic knee pain. On November 28, 2023, you were contact guard to 
supervision for transfers, toilet transfers, and ambulation. Per chapter 8, you are functioning at a home care 
level and able to improve with repetitive exercise and support from nonskilled personnel. Daily skilled services 
are 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth 
per quadrant (D4341 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the 
Plan's denial. 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 has been previously exhausted. Specifically, the Plans contract 
states that periodontal scaling and root planing is covered once per quadrant, every 24 months.   
 
 
 
 
You previously received these services on March 31, 2023 and April 5, 2023, less than 24 months prior, which 
were paid for by the Plan. Therefore, you have exhausted the allowable benefit for the requested services in this 
case at this time. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root 
planing-four or more teeth per quadrant (D4341 x 2).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 20 one-way transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that the services are medically 
necessary. The Plan denied your request. The Plan says you have exceeded your benefit for the calendar 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 an additional 20 one-way transportation trips.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve the skilled nursing, physical therapy, and occupational therapy 
home visits. 
 
You asked the Plan to pre-approve home health services. You say that you are finally making progress in 
therapy and all that will go to waste if you cannot continue skilled care.  The Plan denied your request. The 
Plan says that the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows you are homebound. Your prior level of function was non-ambulatory but modified 
independent with transfers and required assistance with self-care tasks. You currently require max assist with 
transfers but have shown progress with standing tolerance and there are appropriate home health skilled 
physical therapy goals of min assist with sit to stand transfers and bed mobility including medical equipment 
evaluation which have not yet been met. The documentation shows you are high risk for recurrent cellulitis if 
proper lower body care is not continued thus the records show that 11 home health physical therapy visits and 7 
home health occupational therapy visits are required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve the skilled nursing, physical therapy, and occupational therapy home visits.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional extraction, of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says your benefit for the requested service 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 service was exhausted on date of service October 6, 2023.  
  
 
 
 
 
Specifically, the Plans contract states that one dental extraction is covered per year. The Plan previously 
authorized a dental extraction for you on October 6, 2023. Therefore, you have exhausted the allowable benefit 
for the requested service in this case. Therefore, we decided that the Plan does not have to pre-approve an 
additional extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the OON physical therapy. You say that the OON physical therapy is 
necessary for the enrollee. The Plan denied your request. The Plan says the services can be provided for the 
enrollee, in-network as the services are not urgent or an emergency. 
 
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 
the physical therapy services to be provided by an out-of-network (OON) provider.
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 is ready to transition to and 
will benefit from a LTACH to regain maximum prior level of functioning. The Plan denied your request. The 
Plan says the enrollee's care can continue to be provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Given there are offered alternatives, LTACH 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the medication. You say that based on the National Comprehensive Cancer 
Network guidelines and the study by Zhang and colleagues you are requesting this chemotherapy combination. 
The Plan denied your request. The Plan says the requested treatment order of Keytruda is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medication. Our physician reviewer 
found the requested use of Keytruda is not FDA-approved for the enrollees diagnosis because it's not approved in this combination and not for first line with planned radiation. The use is not indicated, supported or 
recommended in any of the compendia. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied CGM and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).