Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it would be more convenient for you to stay in the 
rehabilitation center due to its location. The Plan denied your request. The Plan says rules for IRF care have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET scan. 
 
You asked the Plan to pre-approve a PET scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the 
documentation does support that the requested PET scan is medically reasonable and necessary. Our physician 
reviewer found the enrollee has stage IV non-small-cell lung carcinoma, treated with chemo immunotherapy. 
The documentation supports that the enrollee has not had three scans. Therefore, the enrollee meets criteria for 
the requested PET scan as subsequent treatment strategy. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a PET scan.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiotherapy. 
 
You asked the Plan to pre-approve proton beam radiotherapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 proton beam radiotherapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is 
superior to or more beneficial than intensity-modulated radiation therapy/image-guided radiation therapy 
(IMRT/IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy 
on clinical trials, and to not routinely offer it to enrollees. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiotherapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton beam radiotherapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone grafting (21210, 21215) and dental implants 
(21248). 
 
You asked the Plan to pre-approve bone grafting and dental implants. You say that the services are necessary. 
The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 bone 
grafting (21210, 21215) and dental implants (21248).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. You asked the Plan to pre-approve foot orthotics. You say that you have pain in your feet when you walk. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 now medically stable for transfer and the LTACH has a bed for her. The Plan denied your request. The Plan says the enrollee's care can 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 appears to be improving, but is not yet stable enough to transfer at this time. The enrollee requires additional acute care services for the short-term. The enrollee does not require any services at the LTACH which are not already available at the current facility. Continued care at the current facility is appropriate until the enrollee is stable enough for discharge to a lower level of care at a later 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy (unilateral 
or bilateral with decompression of spinal cord, single vertebral segment; lumbar (CPT Code 63047) and 
laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, single 
vertebral segment; each additional segment, cervical, thoracic, or lumbar (CPT Code 63048). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure remains experimental at this time. More research is needed to show the safety 
and efficacy of the procedure. More conservative measures are needed. A recent trial and failure of physical 
therapy (PT) should be documented. Surgery is not needed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression 
of spinal cord, single vertebral segment; lumbar (CPT Code 63047) and laminectomy, facetectomy and 
foraminotomy (unilateral or bilateral with decompression of spinal cord, single vertebral segment; each 
additional segment, cervical, thoracic, or lumbar (CPT Code 63048).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Superion spacer is experimental. More research is needed to show 
safety and efficacy. It is not needed in this case. There is no documented spinal instability. 
 
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 Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper dentures (D5110) and partial lower 
dentures (D5226). 
 
You asked the Plan to pre-approve complete upper dentures and partial lower dentures. You say that the items 
are necessary. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 
complete upper dentures (D5110) and partial lower dentures (D5226).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spiriva 18mcg cp-handihaler (J3535). 
 
You asked the Plan to pre-approve Spiriva 18mcg cp-handihaler. You say that the medication is necessary. The 
Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D 
prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Spiriva 18mcg cp-
handihaler (J3535).  
 
Benefits for Spiriva 18mcg cp-handihaler 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: Favorable

 
We decided that the Plan has to pre-approve MRgFUS (0398T). 
 
You asked the Plan to pre-approve the MRgFUS. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says that the member does not meet 
coverage criteria for the service at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRgFUS. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the U.S. Food and Drug Administration has approved a focused ultrasound device to treat 
essential tremor in patients who have not responded to medication. The member's essential tremor condition is 
refractory to medical therapy. 
 
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 MRgFUS have been met. Therefore, we decided that the Plan has to pre-
approve MRgFUS (0398T).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
You asked the Plan to pre-approve the bone marrow aspiration. You say that you would like reconsideration 
because this procedure is medically necessary. The Plan denied your request. The Plan says the member does 
not meet criteria for this procedure. 
 
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 bone marrow aspiration. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found bone marrow aspiration remains experimental in cases of spinal fusion 
surgery. 
 
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 bone marrow aspiration have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bone marrow aspiration.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve the testing. You say that you would like reconsideration because this test is 
necessary and recommended to use for mental evaluation to diagnose and address the progressive memory loss. 
The Plan denied your request. The Plan says the member does not meet the criteria for coverage of this service. 
 
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 testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the information provided it does not appear that this member meets the criteria for the 
use of neuropsychological testing as the evaluation through a psychiatric evaluation would be more beneficial. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve neuropsychological testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four crowns and four core buildups, including any pins 
when required. 
 
You asked the Plan to pre-approve the crowns and core buildups. You say that you need these services for a 
pre-existing condition. You also say that these services are not for cosmetic purposes. The Plan denied your 
request. The Plan says these services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 four 
crowns and four core buildups, including any pins when required.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the light kit, medical necessities bag hook, direct back 
frame, modified leg assembly, and the power seating elevation feature. 
 
You asked the Plan to pre-approve the additional wheelchair components. You say that you need the power 
seat elevation feature in order to be able to do some household activities for yourself. You feel that this should 
be considered medically necessary in your case as well as the angled foot rest. The Plan denied your request. 
The Plan says the power wheelchair has been approved but the additional components were denied for not 
being primarily medical in nature. 
 
The Plan follows Medicare rules. Medicare rules say that items must be medically reasonable and necessary to 
be covered. Durable medical equipment (DME) must serve a purpose which is primarily medical in nature to 
be considered a covered benefit. Power seat elevation specifically is found to be not primarily medical in 
nature. 
 
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 additional wheelchair components. 
Our reviewer says that the requested modified angled footrest and back assembly are not considered medically 
necessary. Our physician reviewer found the requested leg rest and back rest assembly will not alter or modify 
patient's functional ability, disease management, or ability to use the power wheelchair safely and effectively. 
 
We looked at this physician's review, the file, and Medicare rules. We find that the light kit and bag hook are 
convenience features which do not have a direct therapeutic benefit. In addition, although the power seat 
elevation system may be useful and appropriate, Medicare has decided that it does not meet the definition of 
DME and, as such, is not within a covered benefit category. Based on this information, we decided that 
Medicare rules for coverage of the additional wheelchair components have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the light kit, medical necessities bag hook, direct back 
frame, modified leg assembly, and the power seating elevation feature.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Spacer. 
 
You asked the Plan to pre-approve the device. You say that you would like reconsideration because this device 
is medically necessary. The Plan denied your request. The Plan says until efficacy has been established, this 
item is not a covered benefit. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is considered experimental/investigational. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Vertiflex Superion Spacer.