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

 
We decided that the Plan has to pre-approve a reduction mammaplasty. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there is no documentation of a failure of conservative therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 procedure. Our reviewer says that 
the requested procedure is considered medically reasonable and necessary in this case. Our physician reviewer 
found you are a 37 year old female with evidence of severe symptomatic macromastia that has failed treatment 
with reasonable conservative management (conservative analgesia, supportive bras, etc).  Your photographs are 
supportive of your severe macromastia and clinical scenario of functional impairment. You clearly satisfy the 
Medicare medically necessary criteria. The degree of resection planned is consistent with a significant breast 
reduction. 
 
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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve a reduction mammaplasty.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown-porcelain tooth 30 (D2740) provided March 11, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration for payment 
for D2740. The Plan denied your request. The Plan says this service is not covered under the plan 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. The health plan contract says 
that any services not listed are not covered.  
 
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 pay for crown-
porcelain tooth 30 (D2740) provided March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peridontal scaling and root planing and related 
drugs/medicaments for the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says D4341 requires that the enrollee has a minimum of four teeth. 
 
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 dental 
services 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 dental services. Our reviewer says 
that the requested dental services are not medically reasonable or necessary. Our physician reviewer found the 
request has been made for two quadrants of scaling and root planing on the lower arch under code D4341.  This 
code is reserved for the treatment of four or more involved teeth in a quadrant. In this case the only remaining 
teeth are 17,21,22,27,28 and 30. This translates into three teeth in either lower quadrant, and as the requested 
code requires there be four or more involved teeth in a quadrant, the code would not be applicable. The 
requested D9630 code for medication for use at home is not a covered service under the Plan. Given the lack of 
a sufficient number teeth in a quadrant under code D4341, there is no medical necessity for the requested 
procedures. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve peridontal scaling and root planing and related drugs/medicaments for the enrollee.
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 the orthotics are 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's 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 admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the submitted documentation and medical records have not shown that this level of care 
is 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 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 or can tolerate an 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external infusion pump. 
 
You asked the Plan to pre-approve an external infusion pump. You say that this is medically necessary. The 
Plan denied your request. The Plan says that you do not meet criteria for coverage. 
 
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 an external infusion pump. Our 
reviewer says that an external infusion pump is not considered medically reasonable and necessary in this case. 
You have type 2 diabetes and are using over 100 units of insulin per day. Your C-peptide on 3/13/2020 was 
2.5, which is normal. Your last A1C level was 6.2, however, fasting glucose readings range from 40-400, 
according to the prescribing physician. Kidney function appears to be normal enough to suggest the C-peptide 
reading was fairly accurate. Our physician reviewer found that your condition does not meet Medicare criteria 
for an external infusion pump. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external infusion pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external infusion pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power mobility device (PMD) and accessories 
(K0861, E1007, E2361, E2377 E1028, E2602, E2313 E0955, E2311, E1012). 
 
You asked the Plan to pre-approve a group 3 PMD. You say that the group 3 PMD is medically necessary. The 
Plan denied your request. The Plan says Coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power mobility device (PMD) and accessories (K0861, E1007, E2361, E2377 E1028, E2602, E2313 
E0955, E2311, E1012). Please note that since the base unit does not meet coverage criteria, the accessories 
requested are also non-covered.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right sided C3-C5 facet joint injections. 
 
You asked the Plan to pre-approve the facet joint injections. You say that you feel this is necessary. The Plan 
denied your request. The Plan says the documentation does not support that the LCD criteria are met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be covered when the above 
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 the facet joint injections. Our reviewer 
says that the criteria for the requested injections are not met in this case. Our physician reviewer found the 
enrollee is a female with chronic neck pain and who had a set of diagnostic facet joint injections and achieved 
70% pain relief according to a fax cover sheet. She is taking Butrans and Percocet for pain. There is no 
documentation of Physical therapy, Chiropractic therapy, or an NSAID trial. The request is for 2 levels of 
diagnostic facet blocks. As there is not sufficient documentation of conservative care and the prior injection did 
not provide greater than 80% relief, the request 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 the facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve right sided C3-C5 facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says genicular nerve blocks are investigational.
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 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 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stationary gaseous oxygen system (E0424). 
 
You asked the Plan to pre-approve the oxygen system. You say that the system is medically necessary due to 
power outages. The Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that a stationary gaseous oxygen system (E0424) and 
related contents (E0441) are covered for the treatment of cluster headaches for beneficiaries enrolled in a 
clinical trial. 
 
We looked at the file and Medicare rules. The record does not show that the equipment is requested for cluster 
headaches. Oxygen tanks for power outages are not covered. Based on this information, we decided that 
Medicare rules for coverage of the oxygen system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a stationary gaseous oxygen system (E0424).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed with bedside rails and 
mattress (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that your current bed was donated to 
you 6 years ago. You are asking for a replacement so that you can continue to care for yourself properly and 
remain on your own. The Plan denied your request. The Plan says this item is not covered under Medicare. The 
plan has instead approved a semi-electric hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed with bedside rails and mattress (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says Durable Medical Equipment for outside the home is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The record shows the enrollee has a 4-wheel walker for use within the home. There has been no evaluation to 
determine if a power scooter is medically necessary. The record shows the item at issue in this appeal is for use 
outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for 
use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyeglasses (frames and lenses). 
 
You asked the Plan to pre-approve the eyeglasses. You say that you should be able to get new glasses because 
your vision significantly changed. The prescription that was written last week won't be any good in 2021 
because you know your eyes will get worse. The Plan denied your request. The Plan says this request exceeds 
the benefit frequency limitation. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan?s eyewear benefit covers up to $300 for eyeglasses or contact lenses every 2 years. The 
eyewear benefit is only available once every 2 years. The records show this service was last provided June 10, 
2020.  
 
We looked at the file and the Plan's rules. eyewear is covered once every 2 years. Based on this information, we 
decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the 
Plan does not have to pre-approve eyeglasses (frames and lenses).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no joint contracture that is not responding to standard measures including 
physical therapy. 
 
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 device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the 
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy. The 
requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to 
improve the functioning of a malformed body member. A review of the literature reveals that there are few 
studies on the myoelectric elbow wrist hand orthosis with inconsistent outcomes in post stroke hemiparetic 
patients. 
 
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 powered upper extremity range of motion assist device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental consultation (D9310) and surgical extraction 
(D7210) to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that your dentist advised that an oral surgeon 
will have to perform the services. You would require special treatment to heal properly which the dentist could 
not do. The Plan denied your request. The Plan says dental services performed by an oral surgeon are not 
covered. 
 
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 health plan contract says 
that services must be performed by a participating general dentist. 
 
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 
dental consultation (D9310) and surgical extraction (D7210) to be performed by an oral surgeon.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits for the enrollee. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no need for continue home health nursing visits. 
 
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 the visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found in this case, the 
documentation doesn't support that the enrollee requires skilled nursing services or skilled rehab services to 
provide treatment that is medically necessary.  The enrollee does not require skilled nursing or rehab services 
to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home health skilled nursing visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that you are trying to maintain some form of 
mobility. The Plan denied your request. The Plan says neither Medicare nor your plan  covers care given by a 
massage therapist. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that you have seen this provider for over 
20 years and would like to continue receiving the services. The Plan denied your request. The Plan says you 
must receive your care from a network provider. In most cases, care you receive from an out-of-network 
provider (a provider who is not part of our plan?s network) will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approved these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.