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

We decided that the Plan does not have to pre-approve superion spacer. 
 
You asked the Plan to pre-approve superion spacer. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 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 enrollee has back pain. The requested superion spacer is experimental. More research is 
needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of superion spacer have not been met. Therefore, we decided that the Plan does not 
have to pre-approve superion spacer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gene analysis 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 the genetic testing of many genes that affect response to medications does not meet the 
requirements for approval. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found no medical justification for this test could be found. Knee and back pain is not a common or recognized 
indication for this test. 
 
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 gene analysis for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa capsules for the enrollee. 
 
You asked the Plan to pre-approve Vascepa. You say that Vascepa is medically necessary. The Plan denied 
your request. The Plan says Vascepa is not covered under Medicare Part B. 
 
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 Vascepa capsules for the 
enrollee.  
 
Benefits for Vascepa 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 pay the maximum allowed amount for the complete lower denture, 
the complete upper denture and the unlisted preventive dental service provided on July 6, 2020. 
 
You asked the Plan to pay the maximum allowed amount for the dental services. You say that you have already 
paid $490. You say that you owe an additional $480. You say that the second amount is not paid until the 
dentures are completed. You also say that the annual maximum of $1,000 should be paid for these services.  
The Plan denied your request. The Plan says there is an annual maximum of $1,000 for preventive and 
comprehensive dental services. The Plan says that the annual maximum was exhausted while processing this 
claim. The Plan also says that the unlisted preventive dental service is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the $1,000 annual maximum has been 
exhausted. The record shows that the Plan paid $355 for dental services that you received on June 19, 2020. 
The record shows that the Plan also paid $645 toward the lower denture that you received on July 6, 2020, thus 
the annual maximum has been exhausted. Additionally, the unlisted preventive dental service is not listed as a 
covered service. Therefore, we decided that the Plan does not have to pay the maximum allowed amount for 
the complete lower denture, the complete upper denture and the unlisted preventive dental service provided on 
July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you fell and need help from the rehab to be able to 
regain your strength and ability to walk again. You say that you have nobody to take care of you at home. The 
Plan denied your request. The Plan says you can safely receive the services you need in other settings. 
 
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 that the documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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 IRF admission and services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is not safe to go home until he receives 
intensive rehab. The Plan denied your request. The Plan says that the services are not medically necessary 
because it did not meet Medicare criteria for coverage. 
 
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 the 
enrollee does meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does require 
skilled nursing and/or skilled therapy services on a daily basis. Our reviewer found that the enrollee requires 
moderate to maximum assistance for activities of daily living and mobility and is unable to ambulate. The 
enrollee's physical function has declined, and he is not safe to discharge to his previous living situation with the 
current care he requires. Our physician reviewer also found that admission to a SNF for inpatient skilled rehab 
services is medically necessary for rehab 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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 core build up for tooth 10 and prefabricated post tooth 
for teeth 7, 8, and 9. 
 
You asked the Plan to pre-approve core build up for tooth 10 and prefabricated post tooth for teeth 7, 8, and 9. 
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
requested services are not 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 core 
build up for tooth 10 and prefabricated post tooth for teeth 7, 8, and 9.
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 enrollee requires continuation of 
acute treatment. You say that the enrollee is stable and would benefit from a transfer to an LTACH. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. 
 
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: 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 enrollee is unable to care for himself. The Plan 
denied your request. The Plan says the enrollee does not have daily skilled needs. 
 
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 have documented skilled 
nursing needs.  The enrollee does not have documented skilled therapy needs.  Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The 
enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 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: 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 you do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. You are ambulating more than 100 feet and tending 
to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are 
custodial and, as a practical matter, can be provided 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography with doppler complete 
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 has not been a change in cardiac status or physical examination. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has stable chronic atrial fibrillation, no cardiac symptoms, no new cardiac exam 
abnormalities, no new ECG changes and a prior echocardiogram about 3 years ago with normal ventricular 
function and no significant valve disease. In this circumstance the documentation does not support the medical 
necessity for a repeat echocardiogram. 
 
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 transthoracic echocardiography with doppler complete for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections to be rendered by an OON provider. 
 
You asked the Plan to pre-approve the Botox injections to be rendered by an OON provider. You say that the 
enrollee only wants to be treated by you. The Plan denied your request. The Plan says the request for Botox 
injections is medically necessary and is approved when rendered by a network provider. The Plan also says that 
the request for services to be rendered by an OON provider are not covered. 
 
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 
Botox injections to be rendered by an OON 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 enrollee is stable and suitable for 
transfer to an LTACH. You say that she cannot be adequately cared for at a skilled nursing facility. The Plan 
denied your request. The Plan says the services can be provided in another setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. 
 
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 Mohs micrographic surgery (CPT Codes: 17313 X3, 17314 X3, 14021 X3 and 14020 X3).

You asked the Plan to pre-approve the services. You say that you need this surgery to treat your skin cancer lesion on your thigh that is increasing in size and causing discomfort. The Plan denied your request. The Plan says the services are not 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 physician reviewer found the documentation in the medical records do not support that the coverage criteria for Mohs micrographic surgery have been met in this case. Not covered for healthy patients with primary squamous cell carcinoma without aggressive histologic features on the trunk or extremities. 

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 Mohs micrographic surgery (CPT Codes: 17313 X3, 17314 X3, 14021 X3 and 14020 X3).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for LTACH 
services. The Plan denied your request. The Plan says that the enrollee's records show that the enrollee has not 
completed her full course of care in the hospital. 
 
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. The patient 
appears to be gradually improving but is not stable yet due to low blood pressures and encephalopathy. An 
additional 24 days or less of acute care services should be sufficient to help stabilize the patient enough for 
discharge to a lower level of care. The patient does not require services at the LTACH that they are not already 
receiving at the current facility. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651) and 
bilateral leg sleeves (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device (PCD) (E0651) and bilateral leg sleeves 
(E0667). You say that the requested PCD and sleeves are medically necessary. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for the requested pneumatic compression device (PCD) 
(E0651) and bilateral leg sleeves (E0667). 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device (PCD) 
(E0651) and bilateral leg sleeves (E0667). Our reviewer says that the enrollee does not meet criteria for the 
requested pneumatic compression device (PCD) (E0651) and bilateral leg sleeves (E0667). Our physician 
reviewer found the medical necessity determination for a PCD by the treating practitioner must include 
symptoms and objective findings, including measurements, to establish the severity of the condition. The 
documentation by the treating practitioner of the medical necessity of a pneumatic compression device must 
 
 
include: The patient?s diagnosis and prognosis; symptoms and objective findings, including measurements 
which establish the severity of the condition; the reason the device is required, including the treatments which 
have been tried and failed; and the clinical response to an initial treatment with the device. At a minimum, re-
assessments conducted for a trial must include detailed measurements, obtained in the same manner and with 
reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with 
bilateral comparisons where appropriate. The documentation does not reveal objective detailed measurements 
of  various trials and therapy therefore request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pneumatic compression device (PCD) (E0651) and bilateral leg sleeves 
(E0667) have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device (PCD) (E0651) and bilateral leg sleeves (E0667).