Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve speech therapy services 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 there is no documentation that additional therapy is needed to maintain the current level 
of function. 
 
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 based on the medical records provided, there is no documentation that 
the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Ten 
additional treatment sessions have been approved and ten denied; the enrollee is performing vocal hygiene 
exercises on his own and follow-up with an otolaryngologist for further evaluation is still pending. 
 
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 speech therapy services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT Codes: 33289, C2624) 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the device is necessary. The Plan 
denied your request. The Plan says the device is not 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading 
authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage 
criteria are not met, since the device should still be considered experimental or investigational. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (CPT Codes: 33289, C2624)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs for a stair lift. 
 
You asked the Plan to pre-approve repairs for a stair lift. You say that you require the stair lifts. The Plan 
denied your request. The Plan says that stair lifts are not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While stair lift repairs 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 repairs for a stair lift.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of home care services. 
 
You asked the Plan to pre-approve continuation of home care services. You say that the services are necessary. 
The Plan denied your request. The Plan says the services are not 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 continuation of home care services. Our 
physician reviewer found based on the medical records provided there is no documentation that skilled therapy 
services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's 
level of function, or to establish/perform a maintenance program to maintain the patient's level of function 
and/or prevent deterioration. The enrollee is stable based on records provided with no documentation for need 
for continued skilled 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 continuation of home care services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continuation of home care services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625). 
 
You asked the Plan to pre-approve the ablation procedure. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the requested procedure is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Radiofrequency Ablation of the sacroiliac joint is 
not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ablation procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a radiofrequency ablation procedure (64625).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Intracept procedure (22899, C9752, and C9753). 
 
You asked the Plan to pre-approve a Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 a Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure remains experimental. More research is needed to show 
safety and efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Intracept procedure (22899, C9752, and C9753).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided November 8, 2019. 
 
You asked the Plan to pay for the orthosis. You say that kindly find the attached medical records that proves 
the medical necessity and reprocess the claim. The Plan denied your request. The Plan says the records do not 
support the medical necessity of the orthosis. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found The enrollee was involved in a motor vehicle accident in February 2019. Injuries included a 
lumbar burst fracture for which she was fitted with a lumbar brace prior to hospital discharge. 
 
Follow-up appointment notes indicate the brace no longer fit due to changes in weight.  A progress note dated 
4/30/19 outlined on plans to "hold off" in replacing the ill-fitting brace.  Subsequent documentation does not 
outline the rationale for the requested brace, changes to history or examination, or plan of care related to the 
brace.  Without the medical documentation, medical necessity cannot be determined. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for lumbar-sacral orthosis (L0650) provided November 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found overall the records do not support the medical necessity for nuclear stress 
testing and coverage criteria for nuclear stress testing are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network behavioral health 
provider. 
 
You asked the Plan to pre-approve the referral. You say that you have a good relationship with this provider, 
and he is very skilled. The Plan denied your request. The Plan says the requested provider is not in-network, 
and is not Medicare-certified. 
 
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 
a referral to an out-of-network behavioral health provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete in-vitro fertilization cycle. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says codes with a status indicator of "S" are not approved or paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS codes S4015 and S4021 are not supported in the medical record. Specifically, these codes 
are S codes, which means they cannot be used. 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 
complete in-vitro fertilization cycle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751), a prefabricated post and core in 
addition to a crown (D2954), and a root canal (D3320). 
 
You asked the Plan to pre-approve the dental services. You say that your tooth has been hurting you for a very 
long time. You say that you have lost so many teeth and cannot bare to lose another. You also say that you are 
on a limited income. The Plan denied your request. The Plan says the crown is not listed as a covered service. 
The Plan says a prefabricated post and core in addition to a crown is not listed as a covered service. The Plan 
says a root canal is not listed as a covered service either. The Plan also says any services not listed 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 pre-approve a 
crown (D2751), a prefabricated post and core in addition to a crown (D2954), and a root canal (D3320).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cabazitaxel 1MG Injection (CPT Code J9043) and 
Gemcitabine HCL NOS 200MG Injection (CPT Code J9201). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the Cabazitaxel/Gemzar combination is not FDA approved for this patient's condition. The major drug 
compendia do not currently support the use of this drug combination for the patient's condition. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Cabazitaxel 1MG Injection (CPT Code J9043) and Gemcitabine HCL NOS 200MG 
Injection (CPT Code J9201).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records show that this patient is improving and although requires additional short 
term acute care for additional stabilization and treatment, this should take less than 25 days, and could safely be 
completed at the current facility. The patient does not require services at the LTACH that are not already 
available at the current setting. There are no services at the LTACH that the patient requires that are not already 
available and covered at the current setting. Therefore, this request for LTACH services will be considered not 
medically necessary. Transfer to a lower level of care may be considered when treatment has completed. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic treatment to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve the chiropractic treatment. The Plan denied your request. The Plan says the 
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic treatment to be provided by the requested out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records show that you are improving and although require additional short term 
acute care for additional oxygen weaning, this is likely to take less than 25 days, and could safely be completed 
at the current facility. You do not require services at the LTACH that are not already available at the current 
setting. There are no services at the LTACH that you require that are not already available and covered at the 
current setting. Therefore, this request for LTACH services will be considered not medically necessary. 
Transfer to a lower level of care may be considered soon. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hip surgery (Charn Miller Total Hip Arthroplasty) to be 
performed by an out-of-network provider. 
 
You asked the Plan to pre-approve the services. You say that the member needs to have the service out-of-area, 
as the member as a support system there. The Plan denied your request. The Plan says the Medicare rules have 
not been met. 
 
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. 
 
Based on this information, we cannot approve your request for your hip surgery to be provided by an out-of-
network provider. Also, we follow the Centers for Medicare and Medicaid Services (CMS) Inpatient only list: 
Hip Arthroplasty to determine if this service is appropriate for an inpatient stay. Based on CMS, the hip surgery 
is appropriate for outpatient or observation (usually 72 hours or less) hospital stay.  Therefore, we are unable to 
provide coverage for the inpatient status the enrollee's provider has requested. Furthermore, this provider is out-
of-network for the enrollee's plan and there are in-network providers available to provide these services. 
Therefore, we decided that the Plan does not have to pre-approve hip surgery (Charn Miller Total Hip 
Arthroplasty) to be performed by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided from February 14, 2017, through 
March 13, 2017. 
 
You asked the Plan to pay for the dental services. Your dentist says that your teeth were severely decayed and 
broken due to chemotherapy and the claims should be processed for payment. The Plan denied your request. 
The Plan says the services cannot be covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The file shows that a claim for payment of these dental services was submitted to the medical plan and was 
denied as these are not covered by Medicare. Please note that the services meet the definition of dental 
services, referenced above, regardless of whether the cause of the dental decay was a medical condition.  
 
The Plan provided direction to submit these claims to the dental vendor for payment. These claims were not 
submitted to the dental vendor within one year of the date of service. As such, we find that the denial of 
payment for these services is correct as the rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for dental services provided from February 14, 2017, through March 13, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture for dry mouth. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit for this diagnosis. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for chronic low back pain. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met, as this is being requested for dry mouth. Therefore, we decided 
that the Plan does not have to pre-approve acupuncture for dry mouth.