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

 
We decided that the Plan does not have to pre-approve an additional 36 trips routine transportation. 
 
You asked the Plan to pre-approve additional transportation.. You say that you have no additional 
transportation besides your benefit and currently receiving kidney dialysis. The Plan denied your request. The 
Plan says you have exhausted your benefits. 
 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 60 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 36 trips routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT PNS system. 
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the enrollee suffers from chronic 
intractable knee pain and has tried all conventional treatment options without sustained pain relief. You say that 
this procedure is medically necessary and should be approved. The Plan denied your request. The Plan says this 
device has not been shown to be effective. 
 
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 SPRINT PNS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental therapy for knee pain from osteoarthritis. 
  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 SPRINT PNS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT PNS system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the items are necessary. The Plan 
denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
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 do not think you will get the proper care you 
need at a skilled nursing facility like you will get in the hospital becuase of your diabetes and other medical 
conditions. The Plan denied your request. The Plan says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the mandibular partial denture - flexible base (D5226) 
provided on July 12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the out-of-pocket expense should be 
reimbursed to you seeing how your provider failed to file a claim. The Plan denied your request. The Plan says 
your benefit for the requested item or 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 Plan has paid $1,278 for date of service May 17, 2023, $1,433 for date of service June 7, 2023, and 
$289 for date of service July 12, 2023. Therefore, the annual maximum of $3,000 has been met ($1,278 + 
$1,433 + $289 = $3,000). Therefore, we decided that the Plan does not have to pay more for the mandibular 
partial denture - flexible base (D5226) provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the upper spine (72040), the x-ray of the 
lumbar spine (72100), the office visit (99202), the chiropractic manipulative treatment (98941), mechanical 
traction therapy (97012), group therapeutic procedures (97150), miscellaneous durable medical equipment 
supply (A9900), and the sales tax (S9999) provided on March 20, 2023 to April 6, 2023, by an out-of-network 
(OON) provider.  
 You asked the Plan to pay for the x-ray exam of the upper spine (72040), the x-ray of the lumbar spine (72100), 
the office visit (99202), the chiropractic manipulative treatment (98941), mechanical traction therapy (97012), 
group therapeutic procedures (97150), miscellaneous durable medical equipment supply (A9900), and the sales 
tax (S9999). You say that you called the Plan and they advised you that the x-rays were not covered but the rest 
should have been covered. The Plan denied your request. The Plan says the services provided are available in 
network. 
 
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 x-ray exam of the upper spine (72040), the x-
ray of the lumbar spine (72100), the office visit (99202), the chiropractic manipulative treatment (98941), 
mechanical traction therapy (97012), group therapeutic procedures (97150), miscellaneous durable medical 
equipment supply (A9900), and the sales tax (S9999) provided on March 20, 2023 to April 6, 2023, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual wellness visit provided on September 1, 2023. 
 
You asked the Plan to pay for annual wellness visit. You say that you should not be penalized for going to the 
annual visit a few weeks early. The Plan denied your request. The Plan says you had a paid annual wellness 
visit for date of services October 31, 2022. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for annual wellness visit provided on September 1, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear provided on June 10, 2023. 
  
You asked the Plan to pay for the eyewear. You say that you had to get new glasses due to prescription 
changes. You say you did not get glasses this year. You say this is a new prescription. The Plan denied your 
request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when frames and lenses once every 24 months from the date of 
service. 
 
We looked at the file and the Plan's rules. Specifically, you received eyeglasses on November 1, 2021, which 
exhausted the benefit Based on this information, we decided that the Plan's rules for coverage of the eyewear 
have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear provided on June 
10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prednisone. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve prednisone.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 requires supervision from a Physical 
Medicine and Rehabilitation physician and nursing staff due to complex medical needs. You also say the 
enrollee is below baseline with mobility, balance, and their activities of daily living and that their needs cannot 
be met at a lower level of care. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary based on the enrollee's current functional status and their medical problems are stable.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from May 
11, 2023, to May 31, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the coding was not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 services at issue 
in this case were not supported by the medical records. Our reviewer found that the enrollee did not have an 
active diagnosis of traumatic brain injury or transient ischemic attack. The enrollee did not receive 
parenteral/IV feeds. 
 
We looked at this coder'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 skilled nursing facility (SNF) services rendered from May 11, 2023, to May 31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services. 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says 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 not medically reasonable and necessary. Our physician reviewer found the records do 
not show that skilled nursing services are required to effectively provide treatment, care, and/or services in 
order to improve your condition, or to establish/perform a maintenance program to maintain your condition 
and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively 
provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a 
maintenance program to maintain your level of function and/or prevent deterioration. As skilled nursing and 
skilled therapy are not medically necessary any home health aide services are also not medically 
necessary. Home health aide services are not reasonable and necessary to the treatment of your illness or injury 
by the skilled professional staff beyond the last covered date. 
 
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 not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health care services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. The Plan denied your request. The Plan says the request is 
for massage therapy alone, and not as an adjunctive treatment to another therapeutic procedure. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
  You asked the Plan to pre-approve Synvisc. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred drugs. 
 
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 Synvisc. Our reviewer says that the 
requested drug cannot be recommended. Our physician reviewer found the provided records do not indicate 
that the enrollee has tried and failed the Plan's preferred step one alternative. The records also do not indicate 
that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one 
alternative. 
 
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.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
  You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred drugs. 
 
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 Injectafer. Our reviewer says that the 
requested drug cannot be recommended. Our physician reviewer found the provided records do not indicate 
that the enrollee has tried and failed the Plan's preferred step one alternative. The records also do not indicate 
that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one 
alternative.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) for tooth #24 and #25 and 
a consultation (D9310) provided on May 24, 2023, and June 30, 2023. 
 You asked the Plan to pay for the dental services. You say that the provider ordered the dental services and said 
the bone implant was included. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because the bone replacement graft and the consultation are not covered by the Plan. 
 
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 pay for a bone 
replacement graft (D7953) for tooth #24 and #25 and a consultation (D9310) provided on May 24, 2023, and 
June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital observation services provided on  
November 17, 2021. 
 
You asked the Plan to pay for hospital observation services. You say that the claim was submitted within the 
timely filing limit. The Plan denied your request. The Plan says the claim was untimely, and the submission did 
not meet the exception criteria guidelines outlined in 42 CFR Section 424.44.  
 
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 hospital observation services was not filed until May 31, 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 hospital observation services provided on November 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous laminotomy/laminectomy 
(interlaminar approach) for decompression of neural elements.  
 
You asked the Plan to pre-approve the percutaneous laminotomy/laminectomy. You say that regular Medicare 
covers this surgery. You say that the surgery needs to be done so you can function on your feet again and try to 
get your life back. The Plan denied your request. The Plan says the percutaneous laminotomy/laminectomy is 
not medically necessary. The Plan says the record does not show the enrollee has any sacroiliac disease.  
 
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 percutaneous laminotomy/ 
laminectomy. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found percutaneous laminectomy is experimental and more 
research is needed. 
 
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 percutaneous laminotomy/laminectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the percutaneous laminotomy/laminectomy (interlaminar 
approach) for decompression of neural elements.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided on July 12, 2023. 
 
You asked the Plan to pay for the COVID-19 test. You say that you want to be reimbursed payment. The Plan 
denied your request. The Plan says the item is not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the COVID-19 
test provided on July 12, 2023.