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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee was not able to continue with PT 
services due to Hurricane Laura and went without PT for over a month. Home health physical therapy has not 
been sufficient to address her issues which has led to multiple EMS calls for falls. 
 The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care. Her 
medical condition is not so complex that inpatient level hospital care is required. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is a 69-year-old female with a past medical history of Parkinson's 
disease, hypertension, arthritis, chronic kidney disease and asthma who had a left total knee arthroplasty on 
08/18/2020. She discharged to home with home health services after the hospitalization for the surgery. She 
had some delay in home therapy services due to a hurricane. She is unsteady with pain in the left knee and has 
had falls in her home. She has been to the emergency room for evaluation. She is walking with contact guard to 
minimum assistance and is contact guard to minimum assist for transfers and activities of daily living. There is 
no report of any medically unstable condition. Transfer to an acute inpatient rehabilitation facility is requested. 
 
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical 
therapy and occupational therapy services but based on the medical records provided the patient does not 
require an intensive inpatient rehabilitation therapy program.   
 
 
There is also concern that the patient will not be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue exam by a pathologist provided on February 4, 
2020 by an OON provider. 
 
You asked the Plan to pay for the tissue exam by a pathologist. You say that you are appealing the denial of 
reimbursement for lab testing. The Plan denied your request. The Plan says this service was rendered by an 
OON provider. The Plan also says that this service was available 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 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the tissue exam by a pathologist provided on 
February 4, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1851) suspension sleeve (L2397) and 
straight knee joint, heavy duty (L2385) provided April 4, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of 
the services. The Plan denied your request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or an itemized shipping/billing invoice to indicate the 
specific supplies provided in this case. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for knee 
orthosis (L1851) suspension sleeve (L2397) and straight knee joint, heavy duty (L2385) provided April 4, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3320), Treatment of a root canal 
obstruction (D3331), and Pulp vitality tests (D0460) provided April 29, 2020. 
 
You asked the Plan to pre-approve the dental services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says these items were not covered services under your dental 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 
endodontic therapy (D3320), Treatment of a root canal obstruction (D3331), and Pulp vitality tests (D0460) 
provided April 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that you have great difficulty walking with your walker 
and cannot stand for long periods of time. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar 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 grab bar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental implant placement (D6010) provided May 16, 2019. 
 
You asked the Plan to pay for the implant placement. You say that the service was medically necessary. The 
Plan denied your request. The Plan says implant placement is 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a dental 
implant placement (D6010) provided May 16, 2019.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for plastic surgery services (CPT 15734) provided to the enrollee on 
January 21, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that procedure code 15734-AS-RT is not supported by the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, the CPT Code Manual definition of code 15734 is "muscle, myocutaneous, or fasciocutaneous flap 
of the trunk." 
 
We asked our coding 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 the services. Our reviewer says that the 
services at issue in this case were coded correctly. Our coding reviewer found the operative report documents 
excision of a musculocutaneous flap and then rotated into appropriate position. Closure documented "deep 
subcutaneous tissue with buried sutures of 0-vicryl, I closed the deep dermis with buried sutures of 0-Uicryl. I 
closed the skin with a simply running suture of 2-0 PROLENE". 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
plastic surgery services (CPT 15734) provided to the enrollee on January 21, 2020.  
 
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 the surgical extractions-requiring removal of bone 
and/or sectioning of tooth, for tooth #'s 1, 2, 6, 8, 9, 15 and 16. 
 
You asked the Plan to pre-approve the surgical extractions. You say that the enrollee presented with discomfort 
in the upper arch. You say that the diagnosis is to remove all upper arch teeth that are no longer in good 
condition. The Plan denied your request. The Plan says the documentation submitted does not support the code 
requested. 
 
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 surgical 
extractions 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 surgical extractions. Our reviewer 
says that surgical extractions are not medically necessary. Our physician reviewer found that x-ray does not 
support the presence of tooth #?s 1,2, 6 or 16. Our physician reviewer found that tooth #8, 9 and 15 have 
essentially intact crowns and would not be anticipated to require removal of bone in order to extract the teeth. 
Our reviewer says that as tooth #?s 1,2,6 and 16 are not present, there is no necessity for the surgical procedure 
for these teeth and tooth #?s 8, 9 and 15 would be considered under a lesser code. 
 
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 surgical extractions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the surgical extractions-requiring removal of bone and/or sectioning of tooth, for 
tooth #'s 1, 2, 6, 8, 9, 15 and 16.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says daily doctor treatment is not needed. 
 
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 enrollee is currently undergoing treatment at an ACH following a posterior 
stroke. The enrollee was intubated/ventilated and subsequently received a tracheotomy. There is no evidence 
that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to 
provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee 
can remain at the current ACH until such time no acute services are required. The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brain imaging, PET; metabolic evaluation (CPT Code 78608).

You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our physician reviewer found while the enrollee has had a comprehensive clinical evaluation, the documentation in the case file does not include results of structural imaging such as magnetic resonance imaging (MRI) or computed tomography (CT).

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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve brain imaging, PET; metabolic evaluation (CPT Code 78608).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair replacement. 
 
You asked the Plan to pre-approve the replacement. You say that a wheelchair is needed that can go in the 
grass, has thin wheels, a smaller turning radius, and the chair lifts up. The documentation from your treating 
medical practitioner does not indicate a diagnosis of a neurological condition, myopathy or congenital skeletal 
deformation in the submitted medical progress reports that support the requested Group 3 power wheelchair. 
Furthermore, the request for a power wheelchair that can go in grass, has a smaller turning radius, and lifts the 
chair are not required to perform MRADLs in the home and exceeds your medical needs. The Plan denied your 
request. The Plan says for this to be covered, it must be needed for use within the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
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 replacement. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation is conflicting on whether your mobility deficit is unable to be resolved by a manual wheelchair. 
 
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 replacement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair replacement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular neurostimulation device (64555, L8679). 
 
You asked the Plan to pre-approve the neurostimulation device. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service at issue is considered electro-acupuncture 
and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that auricular electrical devices are non-covered by 
Medicare as electrical acupuncture and the service is not covered when performed at a physician's office.  
 
We looked at the file and Medicare rules. The device is being used as an electro-acupuncture device in a 
physician's office. Based on this information, we decided that Medicare rules for coverage of the 
neurostimulation device have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an auricular neurostimulation device (64555, L8679).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves. 
 
You asked the Plan to pre-approve RFA procedure. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because this procedure 
is experimental/investigational. 
 
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 RFA procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is an experimental/investigational procedure in patients who are status post total knee 
arthroplasty and is the subject of ongoing clinical trials. The enrollee is not enrolled in a clinical trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued intravenous immune globulin (IVIG) 
treatments. 
 
You asked the Plan to pre-approve continued IVIG treatments. You say that the enrollee is having recurrence 
of his symptoms and would be helped by additional IVIG infusions. The Plan denied your request. The Plan 
says there is not sufficient evidence to suggest that an additional dose of IVIG is necessary at this time. 
 
The Plan follows Medicare rules. Medicare rules say that continuation of IVIG treatment must be justified by 
quantitative assessments showing that it is 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 continued IVIG treatments. Our 
reviewer says that the request for continuation of IVIG treatments is not shown to be medically reasonable and 
necessary. Our physician reviewer found the enrollee is a 70-year-old man with a diagnosis of Myasthenia 
gravis without (acute) exacerbation. Three units of IVIG were approved by the plan on 7/9/20, and 2 units were 
approved on 8/7/20. It is documented that the enrollee did respond to IVIG, with expected wearing off of the 
benefit. On 9/24/20, it is documented that the enrollee did not have the energy to get out of chair or to walk. 
 
The case file does not contain quantitative assessment of monitoring of the enrollee's progress. Subjective or 
experiential improvement alone is insufficient to support continued use of IVIG. 
 
 
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 IVIG treatments have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued intravenous immune globulin (IVIG) treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 obstructive sleep apnea 
and obesity-hypoventilation syndrome. There is no diagnosis of chronic obstructive pulmonary disease 
(COPD). Medicare does not cover a home ventilator for these diagnoses. There is no evidence of BiPAP 
failuire. There is also no documentation confirming carbon dioxide retention, which would be necessary to 
qualify for BiPAP. The services are therefore 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 a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor treatment field therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says a recent scan shows progression of the disease. 
 
The Plan must follow Medicare rules. Medicare rules say that tumor treatment field therapy is only covered for 
newly-diagnosed glioblastoma. 
 
The diagnosis in this case is progressive, and not newly-diagnosed. Based on this information, we decided that 
Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tumor treatment field therapy.