Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) head or brain (70450). 
 
You asked the Plan to pre-approve the CT scan. You say that that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says that the records provided do not meet Brain 
CT guidelines and therefore the procedure is 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 the CT scan. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is noted to have undergone replacement of a VP shunt in 11/2019. It is common to 
periodically re-evaluate patients (of all ages) who have undergone VPS placement, to check for shunt related 
complications and the status of a patient's hydrocephalus. In this context/setting the requested service (imaging 
study) would be considered to be reasonable and necessary and would meet Medicare criteria for coverage. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) head or brain (70450).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve repeat medial branch blocks (MBBs). 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat MBBs are covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has chronic low back pain with 
prior lumbar laminectomy and a lumbar epidural steroid injection. He had prior diagnostic MBBs that provided 
87.5 percent pain relief; therefore, repeat MBBs are reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve repeat medial branch blocks (MBBs).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan and myelography of the lumbar spine 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 that there is a lack of clinical documentation showing an indication for the test, or pre-procedural or surgical planning. 
 
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 the services. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has 
classic symptoms of spinal stenosis, and her CT done 5/29/20 confirms multi-level pathology including 
spondylolisthesis at L4-5.  Her prior scan was done without contrast and either MRI or CT myelogram is 
necessary to further and accurately assess the exiting nerve roots and other neural structures since CT without 
contrast does not offer such detail. While the reason MRI has not been done nor is planned as a further step has 
not been discussed in the records, a review of the patient history and physical shows she is 5 feet tall and 
weighs 317 pounds for a BMI of 61. As such she likely is too large in circumference to be accommodated by a 
high field magnet and my indeed exceed the table limit for weight.  The next best procedure for complete 
lumbar spine evaluation would be a CT myelogram.  Thus, the requested exam 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve CT scan and myelography of the lumbar spine for the enrollee.  
 
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the Inspire system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee has never worn the CPAP system at home, only during a sleep study. 
 
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 system. Our reviewer says that the 
requested system is considered medically reasonable and necessary in this case. Our physician reviewer found 
you have obstructive sleep apnea with symptoms. You are unable to tolerate the CPAP interface because of 
claustrophobia, even during CPAP titrations, which could not be successfully completed because of the 
intolerance and inability to sleep with it on. She has tried it on multiple titration attempts with different 
interfaces. 
 
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 system have been met. Therefore, we decided that the Plan has to pre-
approve the Inspire system.  
 
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for acute inpatient hospital care for the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission is medically 
necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 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 acute inpatient hospital care. Our reviewer 
says that Medicare coverage criteria are met. Our physician reviewer found the medical records show at the 
time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital 
care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for acute inpatient hospital care for the enrollee.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve receiver (monitor), dedicated, for use with therapeutic glucose 
continuous monitor system (CPT Code K0554) and supply allowance for therapeutic CGM, includes all 
supplies and accessories, 1 month supply = 1 unit of service (CPT Code K0553). 
 
You asked the Plan to pre-approve the supplies. You say that the supplies are medically necessary. The Plan 
denied your request. The Plan says that the CGM request is being denied as the clinical doesn't indicate you 
check the glucose level 4 or more times per day not does it indicate you are on insulin injections 3 or more 
times per day and requires frequent adjustments. 
 
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 supplies. Our physician reviewer 
found although you do not take insulin, you seem to have a condition that is causing low blood glucose (BG); 
frequent BG checks would seem to be in order to detect low BGS. The dexcom would help alert you to low 
BGS and is medically reasonable in this case;  if you truly have hyperinsulinism, you are at risk for low BGS 
and dexcom is 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 supplies have been met. Therefore, we decided that the Plan has to pre-
approve receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT Code 
K0554) and supply allowance for therapeutic CGM, includes all supplies and accessories, 1 month supply = 1 
unit of service (CPT Code K0553).  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care for the enrollee. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that that there is no clear rationale in the documentation 
nor supportive findings indicating that the member could not have a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that acute inpatient hospital care is medically reasonable and necessary for the enrollee in this 
case. With this patient's comorbid conditions and with known valvular disease that is severe it is reasonable to 
expect that 2 or more midnights would be necessary. Our physician reviewer found that the enrollee's condition 
meets Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care for the enrollee.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the review 
indicates that at the time of the request the member's status is stable and improving. The review indicates that 
the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5211) provided on June 15, 2020. 
 
You asked the Plan to pay for the upper partial denture (D5211). You say that your Evidence of Coverage 
states dentures and extractions are covered. You say that you were also informed that dentures were covered. 
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 pay for the upper 
partial denture (D5211) provided on June 15, 2020.
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does 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 this enrollee 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 dental services provided on May 28, 2019. 
 
You asked the Plan to pay for the dental services provided on May 28, 2019. You say that the 1095-A and 
1095-B forms show that you were enrolled in health coverage through May 31, 2019. You also say that the 
services should be covered. The Plan denied your request. The Plan says while you were enrolled in medical 
coverage on the date of service, you were not enrolled in dental coverage. The Plan also says that your dental 
coverage was not effective until June 1, 2020. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided on 
May 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or 
therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of Clarix graft. 
 
You asked the Plan to pre-approve the application of Clarix graft. You say that the requested application of 
Clarix graft is medically necessary. The Plan denied your request. The Plan says the requested application of 
Clarix graft 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 application of Clarix graft. Our 
reviewer says that the requested application of Clarix graft is not medically necessary. Our physician reviewer 
found the enrollee is with morbid obesity who underwent resection of a massive complex pannus on 9/10/20. 
The enrollee now has an open wound. On 10/23/20, it was noted that the enrollee has a complex abdominal 
wound which is requiring debridement and packing. The documentation is insufficient to support that an 
Amniox Clarix surgical umbilical cord and amniotic membrane matrix tissue graft is medically reasonable and 
necessary for the enrollee 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 the application of Clarix graft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the application of Clarix graft.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided June 7, 2020. 
 
You asked the Plan to pay for the emergency room visit. You say that the service were medically necessary. 
The Plan denied your request. The Plan says a correct claim is required before the claim can be paid. 
 
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 find that CPT code 99285 is not supported in the medical record. Specifically, the claim included an invalid 
diagnosis code. The plan requested a correct claim but none was received. Based on this information, we 
decided that Medicare rules for coverage of the emergency room visit have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency room visit (99285) provided June 7, 2020.