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

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the request is medically necessary and 
beneficial to the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet the 
conditions for this service. 
 
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 continued SNF care. Our reviewer says 
that the requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. 
Our physician reviewer found the enrollee continues to require the level of observation and treatment provided 
in terms of physician oversight and skilled nursing care. Given the complexity of the enrollees medical 
conditions and need for complex wound care, they would continue to benefit from skilled nursing care. The 
enrollee is also noted to have intermittent incontinence and continues to have dysphagia. The enrollee has made 
progress with therapies and currently requires supervision to stand by assistance with mobility and daily 
activities. The enrollee would continue to benefit from speech, physical and occupational therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have been met. The Plan must continue coverage for the 
SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been 
issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve 
continued skilled nursing facility (SNF) 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 treatment of varicose veins of the lower extremities. 
 You asked the Plan to pre-approve treatment of varicose veins of the lower extremities. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says you do not meet 
the requirements for approval.  
 
The Plan follows Medicare rules. Medicare rules say that the patient is symptomatic and has one or more of the 
following conditions such as bleeding from a varicosity. 
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 treatment of varicose veins of the lower 
extremities. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
treatment of spider veins to be considered medically necessary per coverage criteria, there has to be 
documentation that the patient experienced associated varicose bleeding. No varicose bleeding has been 
documented. In addition to not meeting coverage criteria, the absence of varicose bleeding also specifically 
meets a limitation in the coverage criteria. Furthermore, the documentation does not sufficiently establish that 
you are having significant symptoms attributable to the spider veins. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment of varicose veins of the lower extremities have not been met. 
Therefore, we decided that the Plan does not have to pre-approve treatment of varicose veins of the lower 
extremities.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. You say that the continued SNF services are medically 
necessary. The Plan denied your request. The Plan says the continued SNF services are not necessary after 
January 8, 2024. 
 
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 continued 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 clinical documentation shows that you have had clinical and 
functional status change status post hospitalization for congestive heart failure thus would be expected to 
require assessment/treatment by skilled nursing and skilled therapy. Clinical documentation also shows that 
your past level of function was modified independent with mobility and required some assist with activities of 
daily living. Updated therapy notes show that you require supervision with mobility and some assist with self-
care tasks thus all appropriate inpatient daily skilled therapy goals have been met. Clinical documentation does 
not specify any daily skilled nursing needs (receiving wound care every other day) thus daily skilled services 
are not supported. As a practical matter, clinical documentation does not support continued 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary for 
the enrollee's treatment. 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 Rytary.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (MILD). 
 
You asked the Plan to pre-approve MILD. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says you do not meet the requirements for approval. 
 
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 MILD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you were being treated for spondylopathies of the lumbar spine. you presented with low 
back and left hip pain that is rated 2-9/10. The exam reveals intact strength in all 4 extremities. The 
lumbosacral spine showed normal motion. However, the provided magnetic resonance imaging study did not 
corroborate significant central canal stenosis at the L4-5 level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MILD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve minimally invasive lumbar decompression (MILD).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the requested drug is required to treat the enrollee's 
age-related osteoporosis. The Plan denied your request. The Plan says the drug requested is being dispensed 
directly to the enrollee and is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Evenity.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the consultation (D9310) provided on July 24, 2023. 
 
You asked the Plan to pay for the consultation (D9310). You say that you were not told that there would be a 
charge for the consultation if the insurance did not cover the consultation. The Plan denied your request. The 
Plan says that your benefit for the requested item or service has already been exhausted. The Plan says that the 
consultation is not a covered benefit if it is rendered within six months of an oral health examination. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit that you have exhausted three exams in this year. 
Therefore, we decided that the Plan has to pay for the consultation (D9310) provided on July 24, 2023. 
  
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: 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 are asking for the enrollee to be sent to skilled 
nursing to receive physical and occupational therapy in an effort to regain prior level of function and to assist 
the enrollee in navigating the new supplemental oxygen therapy. The Plan denied your request. The Plan says 
the enrollee does not meet Medicare criteria for SNF 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 enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Although further rehabilitation services would be appropriate to improve function, the 
intermittent skilled services can be provided at a lower level of care than 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you would like to request reconsideration of the 
denied PET scan and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is being evaluated for 
dementia. The enrollee was given a clinical diagnosis of AD. In such a setting given that a diagnosis has been 
established (of AD)--there would not be a need to differentiate between AD and FTD. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. You say that the enrollee needs additional SNF 
services. The Plan denied your request. The Plan says the enrollee has no daily skilled nurse or therapist needs. 
 
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 continued 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 enrollee was admitted to SNF for rehabilitation following an 
episode of pneumonia. On January 4, 2024, she was contact guard to supervision and set up for transfers, 
ambulation and self-care. Pneumonia is resolved. The enrollee is functioning at a homecare level and does not 
require daily skilled nursing or therapy services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance (E0673) provided on June 20, 2023. 
 
You asked the Plan to pay for a pneumatic compression device and a garment. You say that the enrollee was 
referred by an in-network provider and was medically necessary for the enrollee's condition. The Plan denied 
your request. The Plan says the requested items were not reasonable or necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 a pneumatic compression device and a 
garment. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has a diagnosis of necrotizing fasciitis. A request was made for a pneumatic compression device 
(E0675) and a segmental gradient pressure pneumatic appliance (E0673) to be used during wound debridement 
surgery. However, a PCD coded as E0675 is used only for peripheral artery disease. Other PCD codes are not 
used for this condition. Therefore, as this patient does not have this diagnosis listed, criteria is not met, and the 
pump will be considered 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 a pneumatic compression device and a garment have not been met.  Therefore, 
we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance (E0673) provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement provided on August 31, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the debridement. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the enrollee must receive their care from a 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 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 debridement provided on August 31, 2023, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injection provided on August 21, 2023. 
 
You asked the Plan to pay for the facet joint injection. You say that the facet joint injection is medically 
necessary. You also say that the enrollee experienced 80% relief and has improved range of motion extension 
and lateral flexion which normally causes pain. The Plan denied your request. The Plan says the facet joint 
injection 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 pay for the facet joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee underwent bilateral diagnostic medial branch blocks from L3 to L5 with 
80% pain relief. The LCD criteria states: "One to two levels, either unilateral or bilateral, are allowed per 
session per spine region. The need for a three or four-level procedure bilaterally may be considered under 
unique circumstances and with sufficient documentation of medical necessity on appeal." There are no 
extraordinary circumstances delineated here. The third level was not medically reasonable and 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 facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pay for the facet joint injection provided on August 21, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee was independently ambulating before 
this critical care hospital stay. The Plan denied your request. The Plan says that the enrollee does not meet the 
requirements for an SNF admission. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has had functional loss during the acute hospital stay.  
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF 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.