Persius/hicric huggingface dataset:
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different 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 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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
needs can be met at an alternate 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 pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not support the need for daily therapy on an inpatient basis. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The enrollee no longer 
requires daily skilled nursing and/or skilled therapy services. She could benefit from continued intermittent 
services at a lower level of care. Although the enrollee made slow progress with therapy, her functional 
improvement has plateaued, and there is no indication that transfer to a skilled nursing facility is required. he 
can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care 
when appropriate. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasonic bone growth stimulator.
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 the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a bone growth stimulator is covered when specific criteria are met. 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 enrollee has a left humerus fracture with surgical repair on February 18, 2021. A follow up x-ray on March 30, 2021 showed a healing fracture in good alignment. There is no documentation of a nonunion fracture on a minimum of two sets of radiographs obtained prior to starting treatment with the bone growth stimulator, separated by a minimum of 90 days. The criteria for coverage are not met and the bone growth stimulator is therefore 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 an ultrasonic bone growth stimulator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tertiary level of care for chemotherapy. 
 
You asked the Plan to pre-approve tertiary level of care for chemotherapy. You say that the requested tertiary 
level of care for chemotherapy is medically necessary. The Plan denied your request. The Plan says the 
requested tertiary level of care for chemotherapy is not medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 tertiary level of care for chemotherapy. 
Our reviewer says that the requested tertiary level of care for chemotherapy is not medically necessary. Our 
physician reviewer found the enrollee is diagnosed with endometrium carcinoma, currently under the care of a 
contracted tertiary-level gynecologist-oncologist who referred the enrollee for chemotherapy to a tertiary care 
facility.  

Based on the documentation provided, the requested tertiary level of care for chemotherapy is not medically 
reasonable and necessary for the enrollee in this case. Carboplatin and paclitaxel is a standard chemotherapy 
regimen. The Plan's denial is medically justified on the basis that it is offering adequate care to meet the 
enrollee's medical needs through referral to a contracted, non-tertiary level provider. There is nothing unique 
about the enrollee's condition that would make it medically necessary for her to see the requested out-of-
network tertiary level of care provider. The Plan has shown that they have in-network providers who meet the 
Standards of Care required for treatment of the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tertiary level of care for chemotherapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve tertiary level of care for chemotherapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested services are medically necessary for 
the enrollee. 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 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 the enrollee was admitted to an inpatient hospital for a diabetic foot ulcer and 
was treated for sepsis, hypoxic respiratory failure, and peripheral vascular disease. 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 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 and/or occupational therapy, there is no documented 
need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with multiple power options. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the notes 
do not show the enrollee has a medical need for the power options. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs and accessories are only covered 
under certain medical indications.  
 
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 requested items. Our physician 
reviewer found that the enrollee does have a neurological condition that would be appropriate for a Group 3 
power wheelchair. He does not use a ventilator. The documentation does not reveal that his needs are at high 
risk for development of a pressure ulcer or utilizes intermittent catheterization for bladder management or 
needs a power seating system to manage increased tone or spasticity. The documentation does not support that 
it is medically necessary to control the requested power options through the joystick (drive interface). His 
strength and functional ability, with independence in feeding, bathing, grooming, meal prep, upper and lower 
limb dressing, toileting and transfers, should be sufficient to control any power options through their own 
switches. The documentation does not reveal that tilt and recline are medically necessary therefore the request 
for Group 3 power wheelchair with multiple power options including the expandable control system is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair with multiple power options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower limb prosthetic accessory alignable system 
(L5910). 
 
You asked the Plan to pre-approve the alignable system. You say that new alignment part will need to be used. 
The Plan denied your request. The Plan says the documentation does not show that the L5910 is damaged 
beyond repair and cannot be re-used for approved socket 
 
The Plan must follow Medicare rules. Medicare rules say that the documentation must include information to 
show why a replacement part is needed. Based on the medical records provided from the prescribing physician 
there is no documentation that the enrollee's prior alignable system components are damaged beyond repair and 
cannot be re-used for the approved socket. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the alignable system have not been met. Therefore, we decided that the Plan does not have to pre-
approve the lower limb prosthetic accessory alignable system (L5910).
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for heart failure, for which he underwent valve surgery and bypass surgery. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that you would like this denture to 
be approved for the enrollee. The Plan denied your request. The Plan says this service exceeds the maximum 
count allowed per period. 
 
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, complete maxillary denture (D5110) is 
limited to one procedure every five plan years. The record shows that the enrollee received a complete 
maxillary denture (D5110) on March 21, 2017, and the enrollee's complete maxillary denture (D5110) benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary 
denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
You asked the Plan to pre-approve the dental services. You say that you are having a hard time eating. You say that you are losing weight. You say that your gum disease has caused your gums to become inflamed and painful. You also say that you struggle to eat daily and need this deep cleaning. The Plan denied your request. The Plan says scaling and root planing 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, scaling and root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and an abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve the prefabricated abutment and abutment supported porcelain/ceramic 
crown. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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 a 
prefabricated abutment (D6056) and an abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable prosthodontic procedure (D5899), complete mandibular overdenture (D5865), two surgical placements of implant bodies; endosteal implants (D6010 x2), and two custom fabricated abutments (D6057 x2).

You asked the Plan to pre-approve the removable prosthodontic procedure, complete mandibular overdenture, endosteal implants, and custom fabricated abutments. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by your dental 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 a removable prosthodontic procedure (D5899), complete mandibular overdenture (D5865), two surgical placements of implant bodies; endosteal implants (D6010 x2), and two custom fabricated abutments (D6057 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no 
documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the 
present acute care hospital. The enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a spinal orthosis (L0650) provided to the enrollee.

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 plan was unable to discover any evidence of an established relationship between the member and the ordering physician.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for the orthosis has been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation and a credible physical examination of the back.

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 pay for a spinal orthosis (L0650) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (90867) 
 
You asked the Plan to pre-approve repetitive transcranial magnetic stimulation. You say that the enrollee has 
been recommended for TMS therapy for better management of depression symptoms, since current medication 
regime is limited due to multiple medication failure and side effects. The Plan denied your request. The Plan 
says the request for this service is not reasonable and 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 repetitive transcranial magnetic 
stimulation. 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, the enrollee has not 
met the criteria for coverage as the requirement is treatment resistance with 4 psychiatric medications in your 
current depressive episode which must be two different classes of psychiatric medications and the doses have 
to have been at the minimum effective dose and duration. At least 2 of the psychiatric medications should have 
been for evidence-based augmentation therapy. The patient does not carry a primary diagnosis of major 
depressive disorder but rather generalized anxiety disorder for which Transcranial Magnetic Stimulation (TMS) 
is not indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repetitive transcranial magnetic stimulation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (90867)