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

 
We decided that the Plan does not have to pre-approve L2-5 decompression and L5-S1 left-sided subarticular 
decompression. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of a failure of conservative treatment to include anti-
inflammatory medications and physical therapy treatment for the current symptoms. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no spine instability documented. There is no recent trial of physical therapy. The 
surgery is not needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2-5 decompression and L5-S1 left-sided subarticular decompression.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7210) of teeth #'s 10, 11, 21, 28, and 29. 
 
You asked the Plan to pre-approve the extractions. You say that the enrollee's doctor recommended extracting 
all poor prognosis teeth before his radiation therapy can be initiated. The Plan denied your request. The Plan 
says the x-rays of these teeth show intact single rooted teeth with adequate and sound supra-osseous tooth 
structure to allow for elevation and tooth removal. The Plan also says that a less severe extraction code would 
be considered. 
 
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 
extractions 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 extractions. Our reviewer says that 
the extractions are not medically necessary. Our physician reviewer found the provided x-rays show teeth with 
notable attrition of the coronal structure of all of the noted teeth. Our reviewer found that despite the heavy 
attrition, there appears to be sufficient structure availability of enough structure to remove these teeth with 
elevation and forceps techniques and not require surgical intervention. Code D7210 is reserved for situations 
where there is the need to cut tissue and bone in order to achieve removal of a tooth.  Where there is sufficient 
remaining coronal structure a lesser code is usually more appropriate. Should a need arise at the time of 
extraction to cut bone to remove a tooth, that can be submitted with treatment notes which show the procedures 
needed at the time of the removal. Our physician reviewer also found that given the current presentation, a 
lesser code should reflect the anticipated non-surgical procedure. 
 
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 extractions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve extractions (D7210) of teeth #'s 10, 11, 21, 28, and 29.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoCycle FES cycling therapy system for the 
enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of this health 
problem. 
 
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 system. Our reviewer says that the 
requested system is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term 
outcomes or patient management associated with the use of FES cycling systems in the management and 
treatment of multiple sclerosis. Therefore per per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 
?411.15(k),  the requested MyoCycle Home FES system is not reasonable and necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a malformed body member. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoCycle FES cycling therapy system for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional physical therapy visits. The Plan denied your request. The Plan 
says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 8 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive therapy for this 
condition and has been authorized additional sessions to review an independent exercise program. Our reviewer 
says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TENS device, four or more leads, for multiple nerve 
stimulation (CPT Code E0730). 
 
You asked the Plan to pre-approve the TENS device. You say that the TENS device is medically necessary. 
The Plan denied your request. The Plan says the TENS device is not 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 TENS device. Our physician 
reviewer found the documentation has not been provided regarding chronicity or of alternative therapies that 
have been tried unsuccessfully prior to use of the TENS unit. 
 
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 TENS device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve TENS device, four or more leads, for multiple nerve stimulation (CPT Code E0730).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the RT300 FES therapy system/FES bicycle for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 evidence for the effectiveness of the RT300 functional electrical stimulation (FES) cycling in people 
with stroke is limited. There is insufficient evidence in the literature that supports that the use of the RT300 
FES will be effective for this patient's stroke or in  individuals  with hemiplegia  in long term improvement of 
muscle strength, vascular blood flow, bone mineral density, reduction of spasticity and atrophy, facilitation of 
functional motor movement or reduction muscle atrophy in the upper and lower extremities. The requested 
RT300 is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as 
it is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member. 
 
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 the RT300 FES therapy system/FES bicycle for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown, core buildup, including any pins when required, and 
endodontic therapy. 
 
You asked the Plan to pre-approve the crown, core buildup, and endodontic therapy. You say that you are in an 
extreme amount of pain, and urgently need these services reconsidered for approval. The Plan denied your 
request. The Plan says that the enrollee needs a follow up after the filling of tooth #17 for a treatment plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable Evidence of Coverage for this 
case. The Plan also did not provide records from the dentist from the date of service that the filling on tooth 
#17 was rendered. We asked for this information multiple times, but it was not provided to us. Without this 
information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or 
that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan 
has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pre-
approve a crown, core buildup, including any pins when required, and endodontic therapy.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary for you to shower. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rezum treatments. 
 
You asked the Plan to pre-approve the Rezum treatments. You say that you would like reconsideration because 
your enlarged prostate is leading to medical complications. The Plan denied your request. The Plan says there 
is no evidence-based literature that shows the Rezum treatments are superior to studied procedures for the 
threatment of a benign, enlarged prostate, with urinary retention. 
 
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 Rezum treatments. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found medical records indicate that this member's prostate is above the appropriate size for 
the Rezum procedure. 
 
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 Rezum treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Rezum treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shingles vaccination. 
 
You asked the Plan to pre-approve a shingles vaccination. You say that this should be covered as preventative 
medicine. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your 
prescription drug plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles 
vaccination. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a shingles 
vaccination. Therefore, we decided that the Plan does not have to pre-approve a shingles vaccination.  
 
Benefits for a shingles vaccination 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approvethe lower partial denture.You asked the Plan to pre-approvethe lower partial denture. You say that the enrollee wants dentures because he is losing teeth.The Plan denied your request. The Plan says that the lower partial denture is not considered an essential 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. The Plan covers the lower partial denture 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 lower partial denture. Our reviewer says that the criteria for coverage has been met. Our physician reviewer found that there are missing mandibular posterior teeth bilaterally.Our reviewer says that a removable partial denture would increase masticatory function, prevent drifting of teeth and provide better stability to the occlusion. Therefore, a lower removable partial denture is reasonable.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 lower partial denture have been met.Therefore, we decided that the Plan has to pre-approvethe lower partial denture. 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 pre-approvefour bone replacement grafts for ridge preservation (D7953 x4), an extraction (D7210) for tooth #6, and removal of residual tooth roots (D7250) for tooth #17.You asked the Plan to pre-approvethe bone replacement grafts, extraction, and removal of residual tooth roots. The Plan denied your request. The Plan says these services are not medically necessary.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 bone replacement grafts, extraction, and removalof residual tooth roots 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 bone replacement grafts, extraction, and removal of residual tooth roots. Our reviewer says that the extraction and removal of residual tooth roots are not medically necessary. Our physician reviewer found the provided radiograph shows an essentially intact tooth #6 with full coronal structure available for a forceps extraction. Given the initial presentation of the tooth, there is insufficient support for the requested extraction. Our reviewer found that tooth #17 presents as remains within thesoft tissue and no bone involvement. Our reviewer also found that as the remaining fragment is entrapped in soft tissue only, the requested code of D7250 is inappropriate and not medically necessary.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 bone replacement grafts, extraction, and removal of residual tooth roots have not been met.Therefore, we decided that the Plan does not have to pre-approvefour bone replacement grafts for ridge preservation (D7953 x4), an extraction (D7210) for tooth #6, and removal of residual tooth roots (D7250) for tooth #17.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), and 
connection (E2311). 
 
You asked the Plan to pre-approve an expandable controller, harness, and connection. You say that these items 
are medically necessary. The Plan denied your request. The Plan says there is not a medical need to control the 
power options through a joystick. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary for the functions 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 an expandable controller, harness, and 
connection. Our reviewer says that the requested items are not medically necessary. Our physician reviewer 
found the documentation does not reveal that you require other types of proportional input devices or non-
proportional input devices. You do not need to operate 3 or more powered seating actuators through the drive 
control, a separate display, other electronic devices, or an attendant control. Your current functional ability 
should enable her to control any power options with their own individual switches. 
 
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 expandable controller, harness, and connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness 
(E2313), and connection (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe extraction (D7210) of teeth # 4 and 13.You asked the Plan to pre-approvethe dental services. You say that  The Plan denied your request. The Plan says the documentation provided does not support the requested service. The Plan also says that the requested service is not medically necessary.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 extractions are not medically necessary. Our physician reviewer found the documentation provided indicates that the coronal structure of teeth #'s 4 and 13 appear intact. The reviewer found that the documentation provided does not support the criteria for coverage for surgical extractions (D7210) of teeth # 4 and 13. Therefore, the requested extractions are not medically necessary.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-approvethe extraction (D7210) of teeth # 4 and 13
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only 
under certain medical indications. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. The records do not indicate the type of power mobility device the enrollee 
current uses. There are insufficient details to show that the current device no longer meets the enrollees needs. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and related 
accessories.