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

We decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging (MRI), any joint of lower extremity.

You asked the Plan to pre-approve an MRI of the right knee (73721). You say that you need a knee MRI because your knees give out. The Plan denied your request. The Plan says there is no documentation of conservative measures.

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 an MRI of the right knee (73721). Our reviewer says that the MRI is not medically necessary. Our physician reviewer found an MRI of the right knee is an appropriate test for the enrollee but the enrollee does not have instability or joint effusion on physical exam and no evidence of fracture. Absent any red flags the medical necessity at this point for MRI has not been established without a 6 week trial of physical therapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the right knee (73721) have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genicular nerve block (RT) (64624). 
 
You asked the Plan to pre-approve Genicular nerve block. You say that it is your position that the denial for 
this procedure is unwarranted and unsupported by the enrollee's current medical status and is inconsistent with 
currently accepted medical practice. The Plan denied your request. The Plan says this is not covered by 
Medicare or the plan. Genicular nerve blocks and genicular nerve ablations are considered investigational for 
the treatment of knee pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-
approve Genicular nerve block (RT) (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplies for a Dexcom continuous glucose monitor 
(CGM) (K0553). 
 
You asked the Plan to pre-approve supplies for a Dexcom CGM. You say that you need this to know when 
your blood sugar is low. The Plan denied your request. The Plan says the criteria for coverage of CGM supplies 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a CGM and related supply allowance are covered 
when the beneficiary has been using a BGM and performing frequent (four or more times a day) testing and 
beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered 
continuous subcutaneous insulin infusion (CSII) pump. 
 
We looked at the file and Medicare rules. The submitted medical records do not show that you are testing your 
blood sugar four or more times a day and are treated with three or more daily insulin injections. Based on this 
information, we decided that Medicare rules for coverage of supplies for a Dexcom CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve supplies for a Dexcom continuous glucose 
monitor (CGM) (K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RFA. 
 
You asked the Plan to pre-approve Radiofrequency ablation (64625). You say that this procedure has provided 
the enrollee with significant and long lasting relief in the past. The Plan denied your request. The Plan says this 
procedure is considered a non-covered service. 
 
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 Radiofrequency ablation (64625). Our 
reviewer says that the requested services is not considered medically reasonable and necessary in this case. Our 
physician reviewer found RFA of the lateral sacral branches is considered experimental/ investigational 
because of the wide variation of efficacy in the peer reviewed literature. Therefore, the request is considered 
not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Radiofrequency ablation (64625) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve RFA.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant /abutment supported removable mandibular 
denture for edentulous arch (D6111). 
 
You asked the Plan to pre-approve the removable mandibular denture. You say that this service is medically 
necessary for the enrollee. The Plan denied your request. The Plan says this service is not covered under the 
enrollee's plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant /abutment supported removable mandibular denture for edentulous arch (D6111).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy and aide services. 
 
You asked the Plan to pre-approve the home health services. The Plan denied your request. The Plan says the 
enrollee does not have any documented needs for skilled home care services. 
 
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 the home health services. Our physician 
reviewer found that the enrollee has had prior skilled nursing facility for wound care. The records do not show 
that skilled nursing or therapy is needed to effectively provide treatment in order to improve the enrollee's level 
of function, or to perform a maintenance program to maintain the patient's level of function, or prevent 
deterioration. As she does not require skilled therapy or skilled nursing services the patient does not meet the 
definition of home health aide services. Therefore, the request for  home health services are not reasonable and 
necessary for the treatment of the enrollee's condition by the skilled professional staff. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy and aide services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surveillance breast MRI. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary, as the lifetime risk is 
over 20%. The Plan denied your request. The Plan says there are no known genetic mutations or family history 
in the chart to support a lifetime risk of 20% or more. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the referring PCP states 
that you have a greater than 20% lifetime risk of breast cancer but there is no reference of what model is used 
to predict same (Gail risk model or other accepted models). There is no documentation of Lynch syndrome or 
BRCA mutation. The physical exam does not reveal any suspicious finding to suggest recurrence. There are no 
mammogram reports describing extremely dense breast tissue or equivocal finding to warrant MRI. There is no 
physical or mammographic finding to suggest implant rupture. Absent any of the above mentioned 
radiographic or clinical abnormalities the medical necessity for breast MRI has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a surveillance breast MRI.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an OmniPod disposable insulin delivery system. 
 
You asked the Plan to pre-approve OmniPod. You say that you have lost motor control of your hands and 
would like to use this disposable device so you would not have to prick your fingers or insert insulin manually. 
The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this 
OmniPod disposable insulin delivery system is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems are not covered 
by Medicare.  
 
We looked at the file and Medicare rules. The requested OmniPod is not covered by Medicare. Therefore, we 
decided that the Plan does not have to pre-approve an OmniPod disposable insulin delivery system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CPAP battery backup. 
 
You asked the Plan to pre-approve a CPAP battery backup. You say that you need a CPAP battery backup 
because the electricity goes out a lot. The Plan denied your request. The Plan says a CPAP battery backup is 
not covered by Medicare and is not included in the benefits of your coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Equipment that is 
presumptively non-medical in nature and used primarily and customarily for a non-medical purpose, even 
though the item may have some remote medically-related use, is not considered DME. Medicare will not pay 
separately or make any additional payment for backup equipment. Therefore, we decided that the Plan does not 
have to pre-approve a CPAP battery backup.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you cannot stand for long periods due to severe 
knee and feet pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve the additional transportation. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says a detailed trip report indicates that 
you have used 24 of the 24 allowed trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled nursing visits. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
had an inferior vena cava (IVC) filter inserted in your heart on July 29, 2020. You have been approved for 
seven skilled nursing visits as of September 1, 2020. The records do not support that further skilled nursing 
services are required to effectively provide treatment, care, and/or services in order to improve your condition, 
or to establish/perform a maintenance program to maintain the your condition, and/or prevent deterioration. 
Your condition is stable and further visits beyond the seven approved by the Plan are not reasonable or 
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 additional home health skilled nursing visits.
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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 you required maximum assistance for lower body activities of daily living. You 
required minimal assistance with transfers. The documentation does not support that you require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not 
support that you require an intensive rehabilitation therapy program. The enrollee's care needs can be met at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the extraction. You say that the tooth needs to be extracted by an oral 
surgeon, and not by a general dentist. The Plan denied your request. The Plan says dental services provided by 
an oral surgeon 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 Plans 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve an extraction to be provided by an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
abdomen/pelvis. 
 
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 non-alcoholic fatty 
liver with chronically mildly-elevated liver tests that are now normal. He has not had an ultrasound since 2018. 
The records do not support the need for a CT of the abdomen/pelvis. An ultrasound would perhaps be 
indicated. The CT scan is 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 a computed tomography (CT) scan of the abdomen/pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray provided on January 9, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you were assured you had dental coverage 
prior to your appointment. The Plan denied your request. The Plan says this service 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 Plans 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 
panoramic x-ray provided on January 9, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep study. 
 
You asked the Plan to pre-approve home sleep study. You say that you need to have this test at home due to the 
COVID-19 pandemic. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because a home sleep test is not indicated given your comorbidities. 
 
The Plan follows Medicare rules. Medicare rules say that home sleep studies may be used to evaluate and 
diagnose obstructive sleep apnea, however they are not intended for enrollees who have certain comorbidities. 
 
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 home sleep study. Our reviewer says 
that you do not meet the Medicare criteria for the requested home sleep testing. Our physician reviewer found 
your past medical history is notable for hypertension, heart disease, chronic obstructive pulmonary disease 
(COPD), insomnia, and obesity. You have dyspnea of unclear cause. You meet coverage indications for a sleep 
study, but not an in-home sleep test. Home sleep studies are indicated only for those enrollees exhibiting signs 
and symptoms of obstructive sleep apnea. Your signs, symptoms, and comorbidities exclude a home sleep 
study but would make an observed sleep study 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 home sleep study have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home sleep study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for a CGM to be covered, the beneficiary must 
be insulin-treated with multiple (three or more) daily injections of insulin.  
 
We looked at the file and Medicare rules. The records provided do not support that the enrollee currently uses 
three or more injections of insulin daily. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Continuous Glucose Monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 2, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 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 did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on June 2, 2020.