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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex 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 a review of the current medical literature indicates that this service is considered experimental and 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 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 the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fitted wheelchair with tilt feature to be provided by an out of network provider.
You asked the Plan to pre-approve a custom fitted wheelchair with tilt feature (E1161). You say that you need a custom fitted wheelchair with tilt feature The Plan denied your request. The Plan says there is no documentation of a home assessment and very little information about your illness. There is no reason for a network exception for out of network services.
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. Medicare rules say that a manual wheelchair will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, or the patient's condition can be ameliorated by a walker or cane, or the enrollee's home does not provide adequate access for use of the manual wheelchair. 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 at issue in this appeal. There is no documentation of the criteria. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a custom fitted wheelchair with tilt feature to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removable unilateral partial denture - one piece cast 
metal (including clasps and teeth), maxillary (D5282). 
 
You asked the Plan to pre-approve the removable unilateral partial denture. You say that you need this item for 
a better quality of life. The Plan denied your request. The Plan says this item is not covered under your 
supplemental 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 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 
removable unilateral partial denture - one piece cast metal (including clasps and teeth), maxillary (D5282).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D6242, D6752). 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are necessary. The 
Plan denied your request. The Plan says these services are not covered under your supplemental 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 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 
dental services (D6242, D6752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary closure of a sinus perforation (D7261). 
 
You asked the Plan to pre-approve primary closure of a sinus perforation. You say that the requested service 
should be covered. The Plan denied your request. The Plan says this service is not covered under your 
supplemental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
primary closure of a sinus perforation (D7261).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. The Plan denied your request. The Plan says 
Medicare does not cover ventilators for the requested use. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested ventilator. Our physician 
reviewer found that a Life2000 system has been requested. This is not a true mechanical ventilator. It provides 
positive pressure during activity, but does not have the full functionality of a ventilator. There is insufficient 
evidence to conclude that this device is beneficial in the treatment of chronic obstructive pulmonary disease 
(COPD).  This enrollee does have COPD, but there is no documentation of carbon dioxide retention while in a 
stable state, which is one of the criteria for nocturnal respiratory support with BiPAP. Therefore, the requested 
device is considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopic retrograde cholangiopancreatography (43264) 
provided on April 17, 2020. 
 
You asked the Plan to pay for endoscopic retrograde cholangiopancreatography. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for endoscopic retrograde cholangiopancreatography. Our 
reviewer says that CPT code 43264 does not meet criteria for billing or reimbursement consideration. Our 
reviewer found the procedure report does not include documentation to confirm a cholangiopancreatography 
(ERCP); with removal of calculi/debris from billary/pancreatic duct(s) was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endoscopic retrograde cholangiopancreatography have not been met. Therefore, 
we decided that the Plan does not have to pay for endoscopic retrograde cholangiopancreatography (43264) 
provided on April 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth - completely bony tooth #16, 
#17, #32 (D7240) and collection and application of autologous blood (D7921). 
 
You asked the Plan to pre-approve the removal of impacted teeth and collection and application of autologous 
blood.. You say that the requested services are necessary. The Plan denied your request. The Plan says the 
requested services are not listed as part of your 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
removal of impacted tooth - completely bony tooth #16, #17, #32 (D7240) and collection and application of 
autologous blood (D7921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood 
glucose testing at least four times per day, and uses insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mandibular partial denture (D5212). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you need the partial denture. 
The Plan denied your request. The Plan says partial dentures are not covered under your supplemental 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 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 
mandibular partial denture (D5212).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the spacer device. The Plan denied your request. The Plan says this 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 the spacer device. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Superion spacer device is experimental. More research is needed to show safety and 
efficacy of the spacer device. 
 
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 spacer device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Superion interspinous spacer device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a CardioMEMS device. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this procedure due 
to his worsening heart failure. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because CardioMEMS is experimental/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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further 
clinical study is needed to determine the efficacy and safety of this device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and electrocardiogram to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and electrocardiogram. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided 
by a network provider. 
 
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 
an office visit and electrocardiogram 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 pay for the lumbar orthosis provided on October 1, 2020.
You asked the Plan to pay for the orthosis. You say that the progress note clearly documents a detailed patient history. The Plan denied your request. The Plan says the enrollee did not receive a video or telephonic visit by the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that spinal orthoses are only covered under certain medical indications.
We looked at the file and Medicare rules. The records provided do not include objective findings that document clinical course, prognosis, nature and extent of functional limitations, other therapeutic interventions and results, or past experience with related items. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar orthosis provided on October 1, 2020.
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 you have several health conditions and might 
fall in the bath from not having balance in your body. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingival irrigation (D4921). 
 
You asked the Plan to pre-approve the gingival irrigation. The Plan denied your request. The Plan says this 
service is not covered under the enrollee's benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
gingival irrigation (D4921).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic lateral sacral branch blocks to be followed with radiofrequency ablation (RFA).
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this 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 the injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 78-year-old woman with chronic low back pain and sacroiliitis. She has had SI joint injections which have provided significant but short-lived relief. She is only taking Tylenol for pain. She has had a home exercise program. RFA of the lateral sacral branches is considered experimental/investigational because of the wide variation in efficacy reported in the literature. Diagnostic blocks as part of the work-up are considered 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic lateral sacral branch blocks to be followed with radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not being prescribed for a medically-accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has poor 
performance status stage IV metastatic squamous cell carcinoma of the lung with unknown PD-L1 status. A 
determination of whether Keytruda for this enrollee satisfies the coverage determination requirements cannot 
be made because the PD-L1 status is unknown. The requested service cannot be recommended. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second Zilretta injection, 32 mg, for the left knee. 
 
You asked the Plan to pre-approve the Zilretta injection. You say that the Zilretta injection has been the only 
therapy that has been successful for your knee pain. You say that you this is the only non-surgical hope for 
treatment that exists for you. You say that there are no studies that specifically cast doubt on the safety or 
efficacy of a second Zilretta injection. The Plan denied your request. The Plan says Zilretta injection are not 
approved by the Food and Drug Administration (FDA) for repeat use and can only be given once per knee, per 
lifetime. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Zilretta injection. Our reviewer says 
that the second Zilretta injection is not medically necessary. Our physician reviewer found the provided 
documentation does not support that the Zilretta is medically reasonable and necessary. The reviewer also 
found that the provided documentation does not support that Zilretta is safe and effective. 
 
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 Zilretta injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a second Zilretta injection, 32 mg, for the left knee.