Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve block of the left knee (64450). 
 
You asked the Plan to pre-approve peripheral nerve block of the left knee. 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 peripheral nerve block of the left knee. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the effectiveness of Genicular nerve blocks to treat knee pain has not 
been established. Genicular nerve blocks are considered experimental/investigational in nature. As such, left 
Genicular nerve block to treat chronic knee pain is 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 peripheral nerve block of the left knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve peripheral nerve block of the left knee (64450).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a variable height hospital bed. 
 
You asked the Plan to pre-approve the variable height hospital bed. You say that you would like 
reconsideration because this bed is medically necessary as the member falls out of bed. The Plan denied your 
request. The Plan says The clinical notes do not support the member meets any of the fixed height hospital bed 
criteria nor the additional variable height criteria as required by Medicare. 
 
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 variable height hospital bed. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not clearly reveal that member's condition has 
failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways 
is not feasible. The documentation does not support a need for an immediate or frequent change in body 
position or special attachments that cannot be fixed on an ordinary bed. The head of the bed does not need to be 
elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or 
problems with aspiration. 
 
 
 
 
 
 
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 variable height hospital bed have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a variable height hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits, destruction of skin lesions and a skin 
biopsy to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve office visits, destruction of skin lesions and a skin biopsy to be provided by 
an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there 
are in-network providers that are able to provide these services. Therefore, coverage criteria has not been met. 
 
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, destruction of skin lesions and a skin biopsy 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 pre-approve adjustable angle footplates and heel loop/holders. 
 
You asked the Plan to pre-approve these services. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
had a right below knee amputation and have been approved for a manual wheelchair. The records note that you 
are unable to use your prosthesis on the right lower extremity due to wounds; therefore, the requested items are 
not medically necessary as they exceed your needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve adjustable angle footplates and heel loop/holders.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 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 based on available records, the patient does not meet CMS coverage criteria for an 
IRF admission. The patient has no medical complexity for an IRF admission. The patient is medically stable 
after a hip fracture and surgery. Course uncomplicated. There is no evidence of need for supervision by 
Physical Medicine and Rehabilitation (PM&R) physician three (3) times a week or needing acute rehab nursing 
care. The documentation does not support that there is a need for an intensive therapy program with 3 hours a 
day and an interdisciplinary approach to rehab care. IRF admission is not medically necessary. The patient does 
not meet the CMS coverage criteria for an IRF admission due to lack of medical complexity. The patient's 
rehab needs can be met safely and effectively in an alternate, less intense setting such as in a skilled nursing 
facility (SNF).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction of teeth #24 and 26 (D7140), extraction of 
erupted tooth requiring removal of bone and/or sectioning of tooth for teeth #21, 22, 27, and 28 (D7210), 
removal of residual tooth roots on teeth #20, 31 and 72 (D7250), and placement of intra-socket biological 
dressing to aid in hemostasis or clot stabilization on teeth #20, 21, 28, and 29 (D7922). 
 
You asked the Plan to pre-approve extraction of teeth #24 and 26, extraction of erupted tooth requiring removal 
of bone and/or sectioning of tooth for teeth #21, 22, 27, and 28, removal of residual tooth roots on teeth #20, 31 
and 72, and placement of intra-socket biological dressing on teeth #20, 21, 28, and 29. 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 
extraction of teeth #24 and 26 (D7140), extraction of erupted tooth requiring removal of bone and/or sectioning 
of tooth for teeth #21, 22, 27, and 28 (D7210), removal of residual tooth roots on teeth #20, 31 and 72 (D7250), 
and placement of intra-socket biological dressing to aid in hemostasis or clot stabilization on teeth #20, 21, 28, 
and 29 (D7922).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan eye drops. 
 
You asked the Plan to pre-approve Zioptan. You say that other drops have caused the eyes to be very irritated. 
The Plan denied your request. The Plan says this drug is not covered for your condition by Medicare Part B. 
 
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 Zioptan eye drops.  
 
Benefits for Zioptan 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: 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 this will be crucial for treatment to relive pain 
and swelling. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick System. 
 
You asked the Plan to pre-approve a Purewick System. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The medical record does not indicate the condition of permanent 
incontinence. This system is not covered by Medicare or the Plan. Based on this information, we decided that 
Medicare rules for coverage of a Purewick System have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Purewick System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057) for teeth # 21 and 
28. 
 
You asked the Plan to pre-approve the dental services. You say that you need this service. You say that you 
need it in order to get your lower denture implants. The Plan denied your request. The Plan says custom 
fabricated abutment is not listed as a covered service. 
 
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 
custom fabricated abutments (D6057) for teeth # 21 and 28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the sinus perforation closure and deep sedation- each subsequent 15-minute increment.
You asked the Plan to pre-approve the sinus perforation closure and deep sedation- each subsequent 15-minute increment. You say that if they are not covered you will have to pay more than $400 that you don't have. The Plan denied your request. The Plan says the services are not covered benefits.
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 Plan also have a maximum benefit of 30 minutes of deep sedation. The Plan pre-approved 30 minutes of deep sedation, which exhausted your benefit. The sinus perforation closure is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve the sinus perforation closure and deep sedation- each subsequent 15-minute increment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057) and abutment 
supported retainer (D6059). 
 
You asked the Plan to pre-approve the custom fabricated abutment (D6057) and abutment supported retainer 
(D6059). You say that the implant abutments and crowns are necessary to restore their dentition, bite and 
overall well-being. You say that there is a medical and dental necessity to continue and finish the implant 
prosthetic treatment. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 the 
custom fabricated abutment (D6057) and abutment supported retainer (D6059).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis, 24mg/3ml, 48 units. 
 
You asked the Plan to pre-approve Hymovis. You say that the enrollee has previously been denied for different 
viscosupplement injections. You say that the enrollee has tried different medications and corticosteroid 
injections without relief. You also say that the enrollee has done some home exercises with no improvement. 
The Plan denied your request. The Plan says Humovis is not a preferred drug. The Plan says that the requested 
viscosupplement is not medically necessary. 
 
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 Hymovis. Our reviewer says that the 
requested drug is not medically necessary.  
 
 
 
Our physician reviewer found the provided documentation does not show a trial and failure of first line 
monovisc or orthovisc. The reviewer also found that recent literature shows that these visco injections are not 
effective. Therefore the reviewer found that the requested drug 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 Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis, 24mg/3ml, 48 units.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis 0.05% emulsion. 
 
You asked the Plan to pre-approve the eye drops. You say that you would like reconsideration because this 
drug is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as 
a benefit exclusion. 
 
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 Restasis 0.05% emulsion.  
 
Benefits for the eye drops 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a coronary computed tomography (CT) scan with 
quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says calcium scoring is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal is being requested solely for screening purposes. Medicare does not cover this 
test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve a coronary 
computed tomography (CT) scan with quantitative evaluation of coronary calcium.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided at a lower level of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require 
intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as 
physical and occupational therapy but the documentation does not support that your functional status requires 
an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 
condition does not meet Medicare criteria for IRF 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 pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee is not eligible for skilled nursing coverage because the 
enrollee needs custodial care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five home health skilled nursing and five home health 
physical therapy visits. 
 
You asked the Plan to pre-approve these services. You say that you need home health to stay out of the 
hospital. 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 these services. Our reviewer says that 
the services are not medically 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 the your 
condition, or to establish/perform a maintenance program to maintain the your condition and/or prevent 
deterioration. You have had extensive prior skilled nursing and were educated in disease management. You 
have no complex wounds or enteral feedings. Your functional level does not require ongoing skilled therapy. 
The continued home health services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve five home health skilled nursing and five home health physical therapy visits.