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

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3320). 
 
You asked the Plan to pre-approve endodontic therapy. You say that the service is necessary. The Plan denied 
your request. The Plan says the service is not a 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 
endodontic therapy (D3320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee currently has a standard oxygen delivery system. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found the records 
do not establish that the enrollee still needs supplemental oxygen. The most recent clinical note indicates you 
are using the oxygen as needed. You already have a portable oxygen system. There is no indication that this 
system does not meet your needs. This request is considered a convenience item. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET CT scan from the skull base to mid-thigh. You say that the services 
are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET CT scan from the skull base to 
mid-thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found while the 
CMS guidelines allow for 1 PET/CT in the evaluation of a pulmonary nodule based upon the coronary 
angiogram procedure (CAG) decision on PET scans made in 2013 the surgeon has provided his analysis of the 
CT scan and a change in the appearance of the process as well as appropriate rationale for planning based upon 
any changes when comparing the prior scan to a new scan. In addition, there is concern not only about the size 
of the nodule but also its semisolid nature which elevates the concern about a slow growing malignancy. For 
these reasons the requested PET/CT should be approved. 
 
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 PET CT scan from the skull base to mid-thigh have been met. Therefore, we 
decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull base to mid-thigh (78815).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 23, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you fell and your lifeline button sent an out 
of network ambulance. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 23, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 23, 
2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRIs of the cervical spine, thoracic spine, and lumbar spine. 
 
You asked the Plan to pre-approve MRIs of the cervical spine, thoracic spine, and lumbar spine. You say that 
the requested MRIs of the cervical spine, thoracic spine, and lumbar spine are medically necessary. The Plan 
denied your request. The Plan says that the requested MRIs of the cervical spine, thoracic spine, and lumbar 
spine 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 MRIs of the cervical spine, thoracic 
spine, and lumbar spine. Our reviewer says that the requested MRIs of the cervical spine, thoracic spine, and 
lumbar spine are medically necessary. Our physician reviewer found the enrollee has undergone L5/S1 anterior 
spine fusion, posterior instrumentation on 9/4/14 and hardware removal L5/S1, L4-5 laminectomy, L4-5 
PSF/TLIF, posterior instrumentation L4 through S1 on 7/10/18. Chief complaint at time of last visit was mid-
low back pain with a "heaviness" feeling to bilateral lower extremities.  
 
The enrollee is complaining of neurologic symptoms -heaviness of legs. An MRI of the spinal axis, cervical 
and thoracic and lumbar is reasonable to see if there is cord compression in any region. The requested MRIs are 
medically reasonable and necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRIs of the cervical spine, thoracic spine, and lumbar spine have been met. 
Therefore, we decided that the Plan has to pre-approve MRIs of the cervical spine, thoracic spine, and lumbar 
spine.  
 
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 a material upgrade (D9999). 
 
You asked the Plan to pre-approve a material upgrade. You say that this makes crowns stronger. The Plan 
denied your request. The Plan says this is 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 
material upgrade (D9999).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you do not have complex medical or intensive rehabilitation needs 
requiring supervision by a rehabilitation physician and an intensive and coordinated interdisciplinary team in a 
resource intensive inpatient hospital environment. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. There is no documentation that you require the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility. Our physician reviewer found that your condition does 
not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. 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 Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the spacer is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete blood count services coded 85025 provided on 
February 12, 2020. 
 
You asked the Plan to pay for the complete blood count services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 85025 is blood count; complete (CBC), automated (Hgb, 
Hct, RBC, WBC and platelet count) and automated differential WBC count. 
 
We find that CPT code 85025 is not supported in the medical record. Specifically, the documentation submitted 
did not include a physician order/lab requisition form or lab results for the billed procedure. Based on this 
information, we decided that Medicare rules for coverage of the complete blood count services have not been 
met. Therefore, we decided that the Plan does not have to pay for the complete blood count services coded 
85025 provided on February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rytary. 
 
You asked the Plan to pre-approve Rytary. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Rytary.  
 
Benefits for Rytary may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Meloxicam 7.5mg tablets. 
 
You asked the Plan to pre-approve Meloxicam 7.5mg tablets. You say that the medication is necessary. The 
Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D 
prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Meloxicam 7.5mg tablets.  
 
Benefits for Meloxicam 7.5mg tablets may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion spacer. You say that this is covered by Original Medicare and 
is supported by the literature. The Plan denied your request. The Plan says the current peer-reviewed literature 
does not clearly support this procedure. 
 
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 Superion spacer. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Superion spacer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Entyvio. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the Entyvio is medically reasonable and necessary or safe and effective for the 
enrollee. The Medicare-approved compendia do not support the use of Entyvio for microscopic/collagenous 
colitis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genicular nerve radiofrequency ablation (64624). 
 
You asked the Plan to pre-approve Genicular nerve radiofrequency ablation. 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 Genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the effectiveness of Genicular nerve blocks, including 
Genicular nerve radiofrequency ablation, to treat knee pain has not been established. Genicular nerve blocks 
are considered experimental/investigational in nature. As such, Genicular nerve radiofrequency ablation to treat 
chronic knee pain is 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 Genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Genicular nerve radiofrequency ablation (64624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22870, 22869). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. 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 Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the spacer is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22870, 22869).
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the 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 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 limited oral evaluation (D0140) provided on July 27, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you cracked your tooth while you were eating. 
You say that your tongue was cut as a result. You also say that you went to the dentist and they ground your 
tooth down so that it would not cut your tongue anymore. The Plan denied your request. The Plan says 1 
limited oral evaluation per plan year is covered. The Plan also says that the frequency limit has been exceeded. 
 
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 and limited oral evaluation is a covered 
service, the frequency limit of 1 per plan year has been exceeded. The record shows that the Plan paid for the 
limited oral evaluation that you received on July 11, 2020. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140) provided on July 27, 2020.