Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
submitted documentation indicates that your needs can be met in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the MRI, abdomen; without contrast material(s), followed by with 
contrast material(s) and further sequences (CPT Code 74183), for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has a known history of pancreatic cysts. 
The Plan denied your request. The Plan says that the MRI is not 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 the MRI. Our physician reviewer found 
the cure rate for pancreatic malignancies is poor. Early detection is very important. The Radiologist reviewing 
the MRI suggested annual follow up exam. The provider wishes for annual follow up MRI. The MRI is 
reasonable and indicated. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
the MRI, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences 
(CPT Code 74183), 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara 130 mg/26 mL intravenous solution. 
 
You asked the Plan to pre-approve Stelara. You say that this medication is medically necessary. The Plan 
denied your request. The Plan says this drug is covered under the Part D drug benefit and is not eligible for 
coverage under the Part B medical benefit as it is usually self-administered. 
 
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 Stelara 130 mg/26 mL 
intravenous solution.  
 
Benefits for Stelara 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: 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 you would like reconsideration because 
the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member is 
receiving the appropriate inpatient acute care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the member does not require any services at the LTACH that are not already 
available at the current facility. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient psychotherapy services. 
 
You asked the Plan to pre-approve the psychotherapy services. You say that the services are medically 
necessary and this provider has helped you. The Plan denied your request. The Plan says this type of provider is 
not eligible for Medicare payment. The enrollee was advised previously to begin transitioning to a covered 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Marriage and Family Therapists (MFTs) are not 
eligible for enrollment in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue is an MFT and is not eligible for Medicare 
payment. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient psychotherapy 
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you lose your balance and you fall a lot due to 
the conditions caused by your flat feet. You say that at this time you have foot pain and your feet are swollen. 
You stated that the requested orthotics would give you the ability to function in a normal capacity. You asked 
the Plan to reconsider their decision because it would be a financial hardship for you to have to purchase the 
orthotics yourself. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen and pelvis
(74177).
You asked the Plan to pre-approve the CT scan. You say that the CT scan 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 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
CT scan is not medically necessary. Our physician reviewer found physical exam of the abdomen was normal.
The presenting symptoms were not acute and there is no follow up information regarding progression of
symptoms or results of the planned evaluation by the gastroenterologist.
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 not been met. Therefore, we decided that the Plan does not
have to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74177).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you had knee surgery on 08/03/2020 and 
have medical appointments to go to. You do not have people to take you to your appointments and is not 
allowed to drive. The Plan denied your request. The Plan says this request exceeds the plan's frequency 
limitation. 
 
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 12 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 trips.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve back surgery: left L5-S1 transforaminal lumbar fusion (22633, 
63047). 
 
You asked the Plan to pre-approve back surgery: left L5-S1 transforaminal lumbar fusion. You say that the 
services are necessary. The Plan denied your request. The Plan says that medical necessity has not been 
established. Therefore, coverage criteria has not been met. 
 
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 back surgery: left L5-S1 transforaminal 
lumbar fusion. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found current evidence based medical literature would support 
this surgical request. There is evidence of progressively worsening symptoms of L5 radiculopathy with clinical 
evidence of motor deficits correlated with left L5 nerve root compression at the L5/S1 level. She has been 
afforded reasonable and/or comprehensive conservative treatment. There is no radiographic evidence of 
spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is discussion supporting 
the need for total facetectomy that would result in temporary intraoperative instability and necessitate fusion. 
Therefore, this request for left L5/S1 transforaminal lumbar interbody fusion with pedicle screw fixation is 
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 back surgery: left L5-S1 transforaminal lumbar fusion have been met. 
Therefore, we decided that the Plan has to pre-approve back surgery: left L5-S1 transforaminal lumbar fusion 
(22633, 63047).  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have had arthritis for over forty years and 
this condition has damaged several joints in your body. You say that the only exercise you are able to do on a 
regular basis is walking and you like to walk ten thousand steps a day. You stated that the orthotics you 
currently have were purchased at a shoe store several years ago and they are wearing out. You asked the Plan to 
reconsider providing coverage for the requested orthotics. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve transcatheter placement of intravascular stent(s) (37215). 
 
You asked the Plan to pre-approve transcatheter placement of intravascular stent(s). You say that the services 
are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. 
Therefore, coverage criteria has not been met. 
 
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 transcatheter placement of intravascular 
stent(s). Our reviewer says that the requested items/services are considered medically reasonable and necessary 
in this case. Our physician reviewer found based on the records that the enrollee had a recent stroke in the 
distribution of the left internal carotid artery with a documented 50% stenosis at the ostium of that artery. In 
this circumstance revascularization of the left carotid artery is reasonable and appropriate and that is what is 
being requested (not verterbal stenting). Coverage criteria for left carotid artery stenting is met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcatheter placement of intravascular stent(s) have been met. Therefore, we 
decided that the Plan has to pre-approve transcatheter placement of intravascular stent(s) (37215).  
 
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 a replacement continuous positive airway pressure device 
(E0601). 
 
You asked the Plan to pre-approve a replacement continuous positive airway pressure device (CPAP). You say 
that you need a CPAP for a better quality of rest. The Plan denied your request. The Plan says that that they did 
not received medical records to support medical necessity. 
 
The Plan must follow Medicare rules. The Plan follows Medicare rules. Medicare rules say that if an item of 
equipment has been in continuous use by the patient on either a rental or purchase basis for the equipment's 
useful lifetime, the beneficiary may elect to obtain a new piece of equipment. 
 
The file indicates you have had your CPAP for over 5 years and that it has been in continuous use. Therefore, 
we decided that the Plan has to pre-approve a replacement continuous positive airway pressure device (E0601).  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve a left sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve the SI joint injection. The Plan denied your request. The Plan says this 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 SI joint injection. Our reviewer says 
that the requested SI joint injection is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the previous therapeutic SI injections did not effectively relieve the pain. A 
repeat left sacroiliac injection 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 the SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left sacroiliac (SI) joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the crown for tooth #21. 
 
You asked the Plan to pre-approve the crown for tooth #21. You say that the tooth has caries and keeps failing 
due to lack of retention. You say that the crown should be considered instead of a filling to provide more 
strength to the tooth. The Plan denied your request. The Plan says the service is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the crown for 
tooth #21 when the services are medically necessary and reasonable.  
 
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 crown for tooth #21. Our reviewer 
says that the criteria for coverage has not been met. Our physician reviewer found that tooth #21 has no loss of 
structure or decay, all cusps are intact, and the tooth has normal bone support. Our physician reviewer found 
that since there is no apparent loss of structure there is no medical necessity for a crown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown for tooth #21 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the crown for tooth #21.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health services, for the enrollee. 
 
You asked the Plan to pre-approve continued home health services. You say that you are requesting review of 
denial of services. The Plan denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued home health services. Our 
physician reviewer found the records do not show that skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a 
maintenance program to maintain the patient's condition and/or prevent deterioration. The patient has had prior 
skilled nursing (SN) and was educated in disease management. There are no complex wounds, new enteral 
feedings or other SN need. The records do not show that skilled therapy is needed to effectively provide 
treatment, care, and/or services in order to improve the patient's level of function, or to establish/perform a 
maintenance program to maintain the patient's level of function and/or prevent deterioration. The patient's 
functional level does not require ongoing skilled therapy. As the patient does not require skilled therapy or 
skilled nursing services the patient does not meet the definition of home health aide services per Section 50.2 
and  home health aide services are not reasonable and necessary to the treatment of the patient's illness or injury 
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 continued home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued home health services, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional ten (10) sessions of hyperbaric oxygen 
therapy services, for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medical records do not indicate that the enrollee currently has 
osteoradionecrosis  (ORN). 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The clinical information we 
received does not meet the guidelines for an extra 10 sessions, as we do not have the results of the first 30 days 
of sessions. Therefore, we decided that the Plan does not have to pre-approve additional ten (10) sessions of 
hyperbaric oxygen therapy services, for the enrollee.
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 you would like reconsideration because 
the LTACH admission is medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare guidelines for care in a LTACH. 
 
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 you do not require any services at the LTACH that are not already available at the 
current facility. 
 
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.