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

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee has not met goals and is 
debilitated due to a chronic diagnosis. The Plan denied your request. The Plan says the additional physical 
therapy visits are not medically necessary. 
 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 the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for the enrollee's condition beyond what was approved by the Plan. The enrollee 
has had prior therapy and the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to provide treatment safely and effectively, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. Education was provided to enrollee 
and caregiver on a home exercise program to maintain current function and safe transfers. The enrollee was 
able to complete the training exercises with the instruction. The enrollee/caregiver have been instructed on 
safety measures, an emergency plan, fall precautions, etc. Ongoing professional therapy 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seat elevation feature, expandable controller, harness, 
and electronic connection. 
 
You asked the Plan to pre-approve a seat elevation feature and upgraded electronics. You say that the requested 
components are necessary for the enrollee. The Plan denied your request. The Plan says a seat elevation feature 
does not serve a medical purpose and is not covered. The Plan also says upgraded electronics are 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 a seat elevation feature and upgraded 
electronics. Our reviewer says that the requested upgraded electronics are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the provided documentation indicates the enrollee has 
use of the upper extremity and can operate and control the power options using the switches that are included in 
the basic wheelchair. Therefore, the reviewer found that the requested upgraded electronics are not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a seat elevation feature and upgraded electronics have not been met. 
Additionally, a seat elevation feature is not a covered benefit. Therefore, we decided that the Plan does not 
have to pre-approve seat elevation feature, expandable controller, harness, and electronic connection.
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 the enrollee did not meet criteria for skilled nursing facility. 
 
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 based on the documentation provided, the enrollee did not require or receive skilled 
services May 5, 2023, through May 12, 2023. The enrollee did not receive daily, skilled nurse services during 
this time period.  Intravenous (IV) antibiotics did not start until May 15, 2023. The enrollee did not require 
daily skilled therapy during this time period. The enrollee was functioning at their baseline 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 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 a group 3 power wheelchair with power options. 
 
You asked the Plan to pre-approve the wheelchair and options. The Plan denied your request. The Plan says 
this not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity.  
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 for the group 3 power wheelchair and power options. 
Our reviewer says that the enrollee does not have myopathy, a congenital skeletal deformity, or a neurological 
condition that requires a Group 3 Wheelchair with power options. 
 
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 group 3 wheelchair with power options have not been met. The file does not 
show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital 
skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair with power options.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the in-home physician visits. 
 
You asked the Plan to pre-approve the in-home physician visits. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are 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 in-home physician visits. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Health Plans denial should be upheld. It is not clear that the enrollee is 
homebound. It is not clear that the enrollee needs to be seen by a provider on a monthly basis. Pre-authorization 
for monthly, provider, in-home visits is not shown to be medically necessary or reasonable. 
 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 in-home physician visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the in-home physician visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision of breast lesion identified by preoperative 
placement of radiological marker, open (19125). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet 
the Medicare 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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the record indicates that the enrollee has sclerosing adenosis without 
atypia. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied, and 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve excision of breast lesion identified by preoperative placement of radiological 
marker, open (19125).
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 wants an extension of the SNF stay. The Plan 
denied your request. The Plan says the continued SNF care 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you cannot afford to pay out-of-pocket. 
The Plan denied your request. The Plan says this is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a fixed bridge (D6740 x 2 and D6245 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that replacing the fixed bridge is the best course 
of action. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
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 when the services are medically necessary and reasonable. The Plans coverage criteria say the 
placement of a fixed prosthetic appliance will only be considered for those cases where there is a documented 
physical or neurological disorder that would preclude placement of a removable prosthesis. 
 
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. Our reviewer says 
that the request meets the criteria for coverage for a fixed bridge replacing teeth number's 29 and 30 with 
pontics using teeth number's 28 and 31 as abutment retainers. Our physician reviewer found that the 
documentation indicates that a bridge was in place replacing tooth number 30. The abutment tooth number 29 
fractured and was deemed non-restorable. A new crown is required for tooth number 31. The only teeth 
missing in the mandibular arch are number's 29 and 30 and the enrollee has an active gag reflex making a 
removable appliance difficult to tolerate. A fixed bridge replacing teeth number's 29 and 30 is the standard of 
care to provide good masticatory function. 
 
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 have been met. Therefore, we decided that the Plan has to 
pre-approve a fixed bridge (D6740 x 2 and D6245 x 2).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the requested drug is not approved by the FDA in this situation. 
 
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 Keytruda. Our reviewer says that the 
requested use of Keytruda is not medically necessary. Our physician reviewer found the provided 
documentation indicates that the enrollee has already failed a PD1 inhibiter. Therefore, the reviewer found that 
the requested use of Keytruda is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an acute inpatient hospital admission and care. 
 
You asked the Plan to pre-approve acute inpatient hospital admission care. You say that the enrollee does not 
have a safe place to go at this time. You say the enrollee has pressure wounds and is unable to walk. You also 
say that you are unable to lift and care or the enrollee. The Plan denied your request. The Plan says that the 
requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital admission care. 
Our reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. 
Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care would span two midnights. Therefore, the 
reviewer found that the inpatient admission criteria have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital admission care have been met. Therefore, we decided 
that the Plan has to pre-approve an acute inpatient hospital admission and care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and consultations (99204, 99214, 99244) 
with a neurosurgeon to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits and consultations. You say that you previously had surgery at 
the requested facility and your condition is getting worst. The Plan denied your request. The Plan says out of 
network services are for emergencies and/or if there is not a contracted specialist in network. Services are 
available with an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits and consultations (99204, 99214, 99244) with a neurosurgeon to be provided by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty (D7311) and the inhalation of nitrous 
oxide (D9230). 
 
You asked the Plan to pre-approve the alveoloplasty and nitrous oxide. You say that you cannot eat because of 
the condition your teeth are in. The Plan denied your request. The Plan says that alveoloplasty (D7311) and the 
inhalation of nitrous oxide (D9230) are not covered by your dental benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
alveoloplasty (D7311) and the inhalation of nitrous oxide (D9230).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back brace (L0637) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a back brace. You say that the item is medically necessary. The Plan denied 
your request. The Plan says there are in-network provider(s) within a reasonable distance from your location 
that can provide this service or item. 
 
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 
a back brace (L0637) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and appliance 
provided on October 21, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) and appliance provided on October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Stretta procedure (43257). 
 
You asked the Plan to pre-approve the Stretta procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Benefits are not available for endoluminal treatment for Gastroesophageal Reflux 
Disease (GERD) using the Stretta procedure, the Bard EndoCinchTM Suturing System, PlicatorTM, or similar treatments as these procedures are not considered reasonable and necessary for the diagnosis or treatment of an 
injury or disease. Currently, these procedures are considered non-covered due to the fact that current peer-
reviewed literature does not support the efficacy of the services. Claims will be denied as "not proven 
effective". 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Stretta procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Stretta procedure (43257).