Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using 
the basic pump that Medicare requires. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
 
 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device 
(E0652).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the lower 
extremity (73722). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the medical documentation does not include a 
history or physical examination relevant to the chief complaint of hip pain.  Clinical impression, differential 
diagnosis, or assessment and plan are likewise not included for review. Without this documentation, the request 
for an MRI cannot be evaluated. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Magnetic Resonance Imaging (MRI) of the lower extremity (73722).
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 appellant needs help with activities of daily 
living and will benefit from rehabilitation so that he can fend for himself. You say that the enrollee is also 
dealing with very advanced Parkinson's. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for coverage of IRF care. The Plan says that the records show that the enrollee's rehabilitation 
and skilled nursing needs are not complex. The Plan says that the enrollee can safely receive the services 
needed in another setting. 
 
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 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 
was admitted for an infection of the gallbladder treated with placement of surgical drain and intravenous 
antibiotics. He has been discharged to home and is receiving home health services. The enrollee's medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. 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 the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
 
You asked the Plan to pre-approve the special supplemental benefits. You say that at the moment of enrolling 
into the plan the representative said that you were eligible for the benefits. After being evaluated you're told 
you are not eligible and this is not what the representative provided. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria established to receive the special supplemental benefits for the 
chronically ill. 
 
The Plan must follow Medicare rules. However, the Plan offers a benefit that exceeds Medicare coverage. For 
that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a special supplemental benefit for the chronically ill in excess of Medicare coverage, 
you do not meet the eligibility requirements listed in the plan benefits on pages 120-124. Based on this 
information, we decided that Medicare rules for coverage of the special supplemental benefits have not been 
met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the 
chronically ill
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
abdomen/pelvis. 
 
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 CT 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
obstructive pulmonary disease, Takotsubo cardiomyopathy, hypertension and depression who has experience 
unintentional weight loss. There is no documentation that a CT scan of the abdomen and pelvis is medically 
reasonable and necessary, given the lack of abdominal or pelvic symptoms on the documented history and 
review of systems and the lack of objective finding on the abdominal examination and the lack of abnormality 
found on laboratory testing. 
 
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 a computed tomography (CT) scan of the abdomen/pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #20. 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the documentation 
does not show evidence of pathologic destruction of tooth #20. 
 
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. The Plan covers the crown 
when the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
crown does not meet coverage criteria. Our physician reviewer found there does not appear to be significant 
coronal breakdown of tooth #20 to warrant a crown restoration (D2750). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth #20.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe outpatient office visits coded as 99204 and 99214.You asked the Plan to pre-approvethe outpatient office visits. You say that you are asking for an appeal for the request for chiropractic intervention with the extreme pain form your lower back down your right limbs at a level 9 on the pain scale.The Plan denied your request. The Plan says services of a chiropractor other than manipulation is not covered.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pre-approvethe outpatient office visits coded as 99204 and 99214.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean over-bed table.You asked the Planto pre-approvethe table. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is considered a convenience item, and not primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plandoes not haveto pre-approvean over-bed table.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingivectomy or gingivoplasty to allow access for 
restorative procedure. 
 
You asked the Plan to pre-approve the gingivectomy or gingivoplasty. The Plan denied your request. The Plan 
says this service is not a covered benefit under the enrollee's 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 
gingivectomy or gingivoplasty to allow access for restorative procedure.
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 records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria for 
inpatient rehabilitation. 
 
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 enrollee is medically stable with no evidence of complex medical issues that 
require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or need 
for acute rehab nursing care. While he may benefit from continuing physical therapy and occupational therapy, 
there is no evidence of a need for an intensive therapy program with or therapy 3 hours per day with frequent 
physician oversight and an interdisciplinary approach to rehabilitation care. Admission to an IRF is not 
medically necessary based on lack of medical complexity and current functional status of CGA for transfers 
and ambulation. The enrollee's rehab needs can be met at an alternate, low intensity level setting such as 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a tertiary-level provider for proton beam 
therapy. 
 
You asked the Plan to pre-approve these services. You say that your doctor recommended proton beam 
therapy. The Plan denied your request. The Plan says the tertiary level of care 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 pre-approve these services. Our reviewer says that 
the tertiary level of care is not medically necessary. Our physician reviewer found the submitted records show 
that you have metastatic prostate cancer and are requesting proton beam therapy. These services can be 
provided safely and adequately by an in-network, non-tertiary provider. The referral to tertiary care is 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 a referral to a tertiary-level provider for proton beam therapy.
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 is medically necessary. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the oral device (E0486). You say that you would like reconsideration
because this supply requires the provider to be both a dentist and durable medical equipment supplier. The Plan
denied your request. The Plan says the requested service is available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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
the medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation 
correction and anatomical localization imaging; whole body (CPT Code 78816) and fluorodeoxyglucose F-18 
(FDG) diagnostic per study dose, up to 45 millicuries (CPT Code A9552). 
 
You asked the Plan to pre-approve the PET scan. You say that when they did the colonoscopy they found a 
cancerous polyp about two (2) years, and these CT scans and PET scan are to make sure everything is okay. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the PET scan have not been met. Your record show that you have a 
polyp but no established diagnosis of cancer and there has been no treatment. Your appeal tells us that you 
want to check on the polyp to be sure it does not return. If your physician believes it is necessary to check on 
the polyp, there are other methods such as a repeat colonoscopy. Therefore, we decided that the Plan does not 
have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization 
imaging; whole body (CPT Code 78816) and fluorodeoxyglucose F-18 (FDG) diagnostic per study dose, up to 
45 millicuries (CPT Code A9552).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seat lift mechanism. 
 
You asked the Plan to pre-approve seat lift mechanism. You say that you have a hard time getting in/out of 
chairs that do not have arm rests. The Plan denied your request. The Plan says the Medicare rules have not been 
met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of seat lift mechanism have not been met. The records received did 
not indicate that you are unable to stand up from a regular armchair or any other chair in your home. Also, 
when coverage is approved for the seat list mechanism, it does not include coverage for the chair, as household 
furniture does not serve a medical purpose. Therefore, we decided that the Plan does not have to pre-approve 
seat lift mechanism.
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 are experiencing plantar fascistic pain. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture (D5110). 
 
You asked the Plan to pre-approve the complete upper denture. You say that you lost your denture a few 
months ago. You also say that you have been losing weight since you are unable to eat without the denture. The 
Plan denied your request. The Plan says the replacement of a lost denture less than 5 years of age is 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 benefit limit for the requested 
upper denture of once every 5 years has been reached. The record shows that you last received a complete 
upper denture. Therefore, we decided that the Plan does not have to pre-approve the 
complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurostimulator implant. 
 
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 neurostimulator implantation 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 chronic pain and low 
back pain. The requested auricular neurostimulator implant is considered experimental/investigational in 
nature. The services do not meet the Medicare criteria for coverage and 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 a neurostimulator implant.