Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care provided to the enrollee 
from January 14, 2021, through January 16, 2021. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this enrollee does not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question as this enrollee 
was not shown to be a danger to themselves or others. The enrollee was not showing any auditory or visual 
hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. We 
looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care provided to the enrollee from January 14, 2021, 
through January 16, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve revision of breast reconstruction with tissue expander replacement. 
 
You asked the Plan to pre-approve these services. You say that you have a known genetic predisposition for 
breast cancer. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that breast reconstruction 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 medically necessary. Our physician reviewer found the records show that the enrollee is in the 
process of undergoing standard breast reconstruction after a bilateral mastectomy. Although she had final 
implants placed as part of the reconstruction, the volumes were considered inadequate and thus underwent 
additional breast reconstruction with tissue expanders to increase volume. Exchange of the expanders for the 
final implants is consistent with breast reconstruction and not cosmetic surgery. The requested procedures are 
not cosmetic in nature and are reasonable and medically necessary to correct defects as a result of disease. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve revision of breast reconstruction with tissue expander replacement.  
 
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the magnetic resonance imaging (MRI) of lumbar spine (72148). 
 
You asked the Plan to pre-approve the MRI of lumbar spine. You say that you need this MRI. The Plan denied 
your request. The Plan says that you do not meet MRI criteria. 
 
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 of lumbar spine. Our reviewer 
says that the service is medically necessary. Our physician reviewer found you present with radicular pain with 
numbness and tingling. Based on the symptoms in the medical records,  the request is consistent with being an 
indication for MRI in question and the service is 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 MRI of lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve the magnetic resonance imaging (MRI) of lumbar spine (72148).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurostimulation trial 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 the records do not show a diagnosis for which this request is 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the criteria for a stimulator is not met. There is no qualified diagnosis. The enrollee has generative low 
back pain. 
 
 
 
 
 
 
 
 
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 a neurostimulation trial for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services from January 19, 2021 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric services. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found you were admitted to the acute inpatient psychiatric hospitalization on 
January 13, 2021 with Major Neurocognitive Disorder with Behavioral Disturbance. Based upon review the 
records provided it was not expected you would improve in a reasonable period of time beyond the dates in 
question as you were not showing any dangerousness to self or others, no obvious auditory or visual 
hallucinations and without aggressive behaviors while not showing any acute threats of safety. The 
documentation shows that you were described as being pleasantly confused. The documentation does not 
support that you meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of January 19, 2021 forward and could have been treated in a lesser restrictive setting as you were not 
showing any suicidal or homicidal ideation, no obvious auditory or visual hallucinations, delusions and was not 
showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to 
safety. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric services from Januyary 19, 2021 forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine irrigation supplies for a urinary 
catheter for the enrollee. 
 
You asked the Plan to pre-approve the additional supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is a request over the allowable limit for these supplies. 
 
The Plan must follow Medicare rules. The rules say that routine irrigations are not covered.  
 
The requested use of the irrigation supplies is not covered by the plan or Medicare. Based on this information, 
we decided that Medicare rules for coverage of the additional supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional routine irrigation supplies for a urinary catheter 
for the enrollee.
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 you need rehab. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not medically necessary. Our physician reviewer found the records show that you were 
admitted to the hospital on January 13, 2021 with right hip and right humerus fractures. You underwent hip 
surgery on January 15, 2021. The physical therapy notes state you need assistance to walk 20 feet and for 
transfers. You are able to bear weight, as tolerated, on your right arm and right leg. The records show that you 
do not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require 
fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
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 pay for the three localized deliveries of antimicrobial agents and 
three gingival irrigations provided on June 22, 2020. 
 
You asked the Plan to pay for the localized deliveries of antimicrobial agents and gingival irrigations. You say 
that you received a receipt for $268.00 and told them you only pay $10.00 for a cleaning. You also say that 
they told you they did a different procedure and received a large bill. The Plan denied your request. The Plan 
says these services 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. 
 
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 the three 
localized deliveries of antimicrobial agents and three gingival irrigations provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urology follow up services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve urology follow up services. You say that due to Covid-19 you are having a 
hard time finding placement for your husband. The Plan denied your request. The Plan says there are in-
network providers available. 
 
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 
urology follow up services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex superion device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has failed conservative treatment. 
The Plan denied your request. The Plan says that experimental and investigational procedures are not covered 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The device is 
experimental. More research is needed to show the safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex superion device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoulder arthroscopy with extensive debridement. 
 
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 items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is approved for a Mumford 
procedure described by code 29824. The requested arthroscopy with extensive debridement is not supported in 
conjunction with the approved procedure. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of the request as an exception to guidelines. The services 
are not the standard of care 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 shoulder arthroscopy with extensive debridement.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
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 that the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient is 
living at home and experiencing weakness and falls. Her medical conditions are stable. There are no medical 
needs requiring an inpatient admission. There are no complex nursing or rehabilitation needs. The patient does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from 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 an acute inpatient rehabilitation facility (IRF) admission and services.
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 doctor recommended IRF. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not medically necessary. Our physician reviewer found the submitted records show that 
you were admitted to the hospital on January 14, 2021, with abdominal pain. You had surgery for an ulcer on 
January 15, 2021. The records show that you need minimal assistance for sitting up, standing up, and 
grooming. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to 
need 15 hours per week of rehabilitative services and regular physician evaluation. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has back pain. There is no 
documented instability. The requested Superion spacer is considered experimental in nature, as more research 
is needed to show safety and efficacy. The services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of lateral exostosis (D7471 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services so that you can get 
dentures. The Plan denied your request. The Plan says the removal of lateral exostosis is not listed as a covered 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of lateral exostosis (D7471 x 2).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four home health therapy visits. 
 
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 four visits are approved and four further are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support that you 
require additional skilled rehab services to provide treatment that is medically necessary. You do not require 
additional rehab services to effectively provide treatment, care, and/or services in order to improve your 
condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Four 
sessions have been approved to establish a home exercise program. Your functional status minimally improved 
with therapy and there has been no further progress in improvement. Additional sessions are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve four home health therapy visits.