Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission for a total knee arthroplasty.
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the medical records do not support active complex medical conditions that 
require inpatient 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found you are indicated for left total knee arthroplasty. Under consideration is a request for 
inpatient admission. There is no specific medical comorbidity reported by the provider to support the medical 
necessity of inpatient care over the outpatient observation level of care. There is no evidence that the physician 
expects your medically necessary treatment to span 2 or more midnights. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
Medicare rules. Therefore, this request for inpatient stay for total knee arthroplasty 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient admission for a total knee arthroplasty
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057) and implant 
supported crowns (D6065) for teeth # 3 and 14. 
 
You asked the Plan to pre-approve the dental services. You say that you have no way of paying for these 
services. You say that your crown broke. You say that if you do not get these crowns, your teeth will shift. You 
also say that your temporomandibular joint (TMJ) pain will get worse as a result. The Plan denied your request. 
The Plan says dental services that are not listed are not covered. The Plan says custom fabricated abutments are 
not listed and therefore are not a covered service. The Plan also says implant supported crowns are not listed 
and therefore are not 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 requested dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
custom fabricated abutments (D6057) and implant supported crowns (D6065) for teeth # 3 and 14.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says 
members must receive care from a network provider and in most cases, care received from an out-of-network 
provider will not be covered, except for emergency care or urgently needed service and needed medical care 
that Medicare requires our plan to cover and the providers in our network cannot provide this care 
(authorization is required). 
 
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 physical 
therapy services to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

Wedecided that the Plan does not have to pay forthe chiropractic care.You asked the Plan to pay forthe chiropractic care. You say that a couple years ago the doctor did a referral for chiropractic treatment that was approved. You had a flare up and after a couple of visits, learned that you needed to get another referral .The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria for chiropractic care at this time. The enrollee has been referred to physical medicine and rehabilitation.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. We asked our physician reviewer to carefully review the casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the chiropractic care Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.Our physician reviewer found there are no submitted imaging studies to reveal evidence of a subluxation. In addition, to not exhibiting a subluxation, the submitted documentation reveals no evidence of any examination findings, including, but no limited to, quantifiable measures of range of motion and strength, orthopedic and neurological findings, palpation or postural findings, or any evidence of any objective findings, or imaging results to support the necessity of chiropractic treatment. There is no clinical documentation submitted that supports any chiropractic treatments.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 chiropractic care have not been met.Therefore, we decided that the Plan does not have to pay forthe chiropractic care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the adult car seat. 
 
You asked the Plan to pre-approve the adult car seat. You say that this is necessary because the enrollee slides 
off the seat. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health 
Plan. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the adult car seat.
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 need these to help prevent or delay foot 
surgery. 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: Transportation
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 if information on medical necessity is 
needed, the neurologist can provide that. The Plan denied your request. The Plan says planned transportation in 
excess of the 12 one-way trips is not covered. 
 
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: 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 bunions and arthritis. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete lower denture (D5120).You asked the Plan to pre-approvethe complete lower denture. You say that you lost your denture a few months ago. You also say that you have been losing weight since you are unable to eat without the denture.The Plan denied yourrequest. The Plan says the replacement of a lost denture less than 5 years of age is not a covered benefitMedicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, thePlan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit limit for the requested lowerdenture of once every 5 years has been reached. The record shows that you last received a completelower denture on February 23, 2017.Therefore, we decided that the Plan does not have to pre-approvea complete lower denture (D5120)
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2751) for tooth #32. 
 
You asked the Plan to pre-approve the crown for tooth #32. You say that you are in need of the crown. The 
Plan denied your request. The Plan says that the crown for tooth #32 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 #32 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 #32. Our reviewer 
says that a crown (D2751) for tooth #32 is medically reasonable and necessary. Our physician reviewer found 
tooth #32 is to serve as an abutment for a removable partial. Our reviewer also found that a well-fitting crown 
is essential to provide good retention and stability of the partial denture clasp. 
 
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 #32 have been met. Therefore, we decided that the Plan has 
to pre-approve a crown (D2751) for tooth #32.  
 
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 oral device/appliance used to reduce upper airway 
collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment (CPT Code 
E0486) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the service. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says for this to be covered you should get this care from a doctor or 
other health care provider in your plan. 
 
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 
oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom 
fabricated, includes fitting and adjustment (CPT Code E0486) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveperiodontal scalings and root planings (D4341) of the UL, UR, LL, and LR quadrants.You asked the Plan to pre-approvethe scalings and planings. The Plan denied your request. The Plan says the documentation does not demonstrate evidence of significant bone loss and/or radiographic root-surface calculus on 4 or more teeth per quadrant.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 scalings and planings 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 scalings and planings. Our reviewer says that the criteria for coverage for scaling and root planing have not been met. Our physician reviewer found the few areas of abnormal periodontal pocketing could be managed individually. Our reviewer also found that in general the periodontal pockets arewithin normal limits and there did not appear to be any subgingival calculus.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 scalings and planings have not been met.Therefore, we decided that the Plan does not have to pre-approveperiodontal scalings and root planings (D4341) of the UL, UR, LL, and LR quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesacroiliac joint injections (64451).You asked the Plan to pre-approvesacroiliac joint injections. You say that this is medically necessary.The Plan denied your request. The Plan says previous injections have not provided adequate pain relief.The Plan follows Medicare rules. Medicare rules say that if previous diagnostic or therapeutic SI injections of an anesthetic and/or steroid to block the joint for immediate, and potentially long lasting, pain relief have not effectively relieved the pain, further injections would not be considered medically necessary.A positive response should demonstrate initial pain relief greater than or equal to 75% -100% and the ability to perform previously painful maneuvers.We asked our physicianreviewer 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 sacroiliac joint injections. Our reviewer says that the requested injections are not shown to be medically necessary. Our physician reviewer found the documentation indicates that the enrollee has previously had SI injections, and they did not have initial pain relief greater than or equal to 75% -100% with the ability to perform previously painful maneuvers. The documented level of initial pain relief was 50%.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approvesacroiliac joint injections (64451).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an SCS trial is 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 not medically necessary. Our physician reviewer found the enrollee has chronic low back pain 
radiating to the leg and peripheral neuropathy. She does not have prior spine surgery, post-herpetic neuralgia, 
peripheral vascular disease or any other approved indication. The enrollee does not meet the criteria for 
coverage of the SCS and it 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 spinal cord stimulator (SCS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ramp with bars. 
 
You asked the Plan to pre-approve a ramp with bars. You say that this is a safety issue and could fall without a 
new ramp. The Plan denied your request. The Plan says that this is not covered. 
 
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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a ramp with bars.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fifteen physical therapy sessions to be rendered by the 
out of network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are available providers within the network that 
can render the services requested. 
 
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 fifteen 
physical therapy sessions to be rendered by the out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair (K0823).You asked the Plan to pre-approvethe power wheelchair. You say that the wheelchair is medically necessary.The Plan denied your request. The Plan says the record shows you are able to move about the home using a walker and the power scooter is primarily for use outside the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. The record shows the home is not wheelchair accessible and the chair is to be stored in a shed outside the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea power wheelchair (K0823).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy. 
 
You asked the Plan to pre-approve these services. You say that you need the services to help control your sugar 
cholesterol levels. The Plan denied your request. The Plan says you do not have a condition for which these 
services are covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vertical bitewings of 7 to 8 x-rays. 
 
You asked the Plan to pay for the vertical bitewings. You say that your dentist told you that vertical bitewing x-
rays were the best x-rays to take. You also say that your dentist advised that this was the best option for getting 
adequate treatment. The Plan denied your request. The Plan says this x-ray is not a set of up to four bitewing x-
rays. The Plan also says that this is a different procedure, and 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 
vertical bitewings of 7 to 8 x-rays.