Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the consultation to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the consultation. You say that you don't want to receive dental treatment at 
your assigned location. You say that you already built trust with the previous clinic and would like to finish 
your dental treatment there. The Plan denied your request. The Plan says you must use providers that are in-
network for all services. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
consultation to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of an oxygen concentrator. 
 
You asked the Plan to pre-approve oxygen concentrator. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of authorization for this device is correct, because the records do 
not show that the enrollee is short of breath most or all of the time or has low oxygen levels. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the 
following blood gas levels: 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is 
evidence of dependent edema, pulmonary hypertension, or erythrocythemia.  
 
 
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 oxygen concentrator. Our reviewer says 
that the enrollee does not meet the Medicare criteria for an oxygen concentrator. Our physician reviewer found 
the enrollee has severe obstructive sleep apnea (OSA). A polysomnography test with positive airway pressure 
(PAP) titration showed 1.6 minutes with oxygen saturations below 89% while breathing room air. This does 
not meet the minimum criteria for oxygen need (which is below 89% for at least 5 minutes). There are no other 
oxygenation measurements in the records. Home supplemental oxygen is 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 oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve use of an oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion. 
 
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 SI joint fusion is covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has pelvic and sacral pain. 
There is no documented joint instability, fracture, or lesion. SI joint fusion for degenerative back pain is 
experimental in nature and 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 sacroiliac (SI) joint fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four osseous surgeries (D4260 x4). 
 
You asked the Plan to pre-approve the osseous surgeries. You say that you need this service done right away 
because you are having trouble eating and it is affecting you. The Plan denied your request. The Plan says this 
service is not covered under your benefit package. 
 
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 four 
osseous surgeries (D4260 x4).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar spine MRI. 
 
You asked the Plan to pre-approve a lumbar spine MRI. 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. 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 a lumbar spine MRI. Our reviewer says 
that the documentation does not support that the requested MRI is medically reasonable or necessary. Our 
physician reviewer found the enrollee has chronic low back pain. The enrollee has had a trial of physical 
therapy prior to the pandemic but has not re-started or done a home exercise program. The enrollee is walking 
with a walker. There is no acute change in signs or symptoms, no focal neurologic deficit or red flag condition 
identified. There is no clear indication identified to repeat the MRI that was performed in Jan 2020. Therefore, 
the enrollee does not meet criteria for the requested 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 a lumbar spine MRI have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar spine MRI.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myopro 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 the records received do not indicate a joint contracture 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 the standard of care for hemiparesis after a stroke over standard treatment including 
treatment such as physical and occupational therapy, strengthening exercises, constraint induced movement 
therapy, Botox injections for spasticity. The American Heart Association/American Stroke Association 
discusses electromyographic biofeedback as used in the Myopro however there is little evidence in the 
literature on how well this device would restore muscle strength post stroke. 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 additional controlled studies of the MyoPro 
Prthosis for upper extremity paralysis after stroke are needed with larger patient groups, consistent 
improvements of relevant outcome functional measures,  and long term follow up. 
 
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 Myopro device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve large joint/joint capsule aspiration for the enrollee. 
 
You asked the Plan to pre-approve the aspiration. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical documentation does not show any quantified degree and duration of 
pain relief, nor improvement outcome. 
 
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 aspiration. Our reviewer says that 
the requested aspiration is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a lack of documentation in that the duration and degree of pain relief from prior 
injections is not clearly defined. Therefore, the request is deemed not medically reasonable or 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 aspiration have not been met. Therefore, we decided that the Plan does not 
have to pre-approve large joint/joint capsule aspiration for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment for the enrollee. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no plan or intention for the enrollee to harm himself or others. 
 
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 the treatment. Our reviewer says that 
the requested treatment is not medically reasonable or necessary. Our physician reviewer found the enrollee 
does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of October 26, 2020 forward and could have been treated in a lesser restrictive setting as he was not 
showing any suicidal or homicidal ideation, 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 the treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve inpatient psychiatric treatment for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespeech therapy to be provided by an out-of-network provider.You asked the Plan to pre-approvespeech therapy. You say that you cannot find a participating provider that can provide the necessary swallowing therapy services.The Plan denied your request. The Plan says services are available in-network.Medicare rules say that plans can require enrollees to getcare 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pre-approvespeech therapy to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
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 enrollee is independent with transfers and activities of daily living. 
 
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 the services. 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 the requested additional therapy is not generally accepted as specific 
and effective therapy for your condition. You have had extensive therapy for this condition and it  does not 
appear that your functional level requires the unique skills of a professional therapist to safely and effectively 
provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. You have been trained in an independent exercise program. The specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain your current condition or to prevent or slow further 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a repeat Urolift procedure. 
 
You asked the Plan to pre-approve the Urolift procedure. You say that you are now having worsening voiding 
symptoms. The Plan denied your request. The Plan says that a repeat Urolift procedure is investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 Urolift procedure. Our reviewer 
says that the requested service is considered medically reasonable and necessary in this case. Our physician 
reviewer found a repeat Urolift procedure in this case is medically reasonable and necessary.  
 
Having a prior Urolift procedure does not preclude repeat Urolift or any other surgical treatment for benign 
prostate hyperplasia. Approximately 13.6% of patients will require a secondary surgical procedure within 5 
years following Urolift. The medical records include the appropriate indications for Urolift. 
 
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 Urolift procedure have been met. Therefore, we decided that the Plan has to 
pre-approve a repeat Urolift procedure.  
 
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-approve an occlusal guard (D9954). 
 
You asked the Plan to pre-approve the dental item. You say that you have requested an occlusal guard multiple 
times. You also say that it has also been denied multiple times. The Plan denied your request. The Plan says 
occlusal guard 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 an 
occlusal guard (D9954).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle continuous glucose monitor. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that you are appealing. The Plan 
denied your request. The Plan says the denial of authorization for this device is correct, because you are not 
using injectable insulin or using an insulin pump. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic continuous glucose monitors are covered 
if all 6 of the above criteria have been 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 continuous glucose monitor. Our 
reviewer says that you do not meet the Medicare criteria for the requested continuous glucose monitor. Our 
physician reviewer found you are not on injectable insulin or on an insulin 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 continuous glucose monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scans of the chest and neck. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has squamous cell 
carcinoma of skin of left upper limb, including shoulder, which was resected with close deep margins, followed 
by skin grafting in March of 2020. An incidental x-ray finding to follow a pulmonary nodule showed a stable 
thick linear opacity in the medial right upper lobe, but showing no obvious evidence of recurrent disease and 
recent physical examination showed no evidence of recurrence. A request was made for CT scans of chest and 
neck. This is a non-melanoma cancer which does not require long-term monitoring in the setting of having had 
follow-up imaging and clinical examination showing no evidence of recurrence. The requested CT scans are 
not reasonable or medically necessary at this time. 
 
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 computed tomography (CT) scans of the chest and neck.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure (228998, C9752). You say that the enrollee has 
disabling pain and the Intracept procedure is medically necessary. The Plan denied your request. The Plan says 
the Intracept procedure is 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 Intracept procedure (228998, C9752). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this procedure is still considered an experimental/ investigational 
procedure. Therefore, the requested procedure is considered not medically reasonable or 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 Intracept procedure (228998, C9752) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered under a Part B medical plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Stelara injection for the 
enrollee.