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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for pneumonia and a urinary tract 
infection Medical problems are stable. There are no identified problems that need inpatient medical 
management. There are no complex nursing or rehabilitation needs. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7210) of teeth #'s 20, 21, 22, 23, 24, 25, 
26, 27, 28, and 29. 
 
You asked the Plan to pre-approve the extractions. You say that these services are medically necessary for the 
health of the enrollee. The Plan denied your request. The Plan says the extractions are 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 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 extractions of teeth #'s 20, 21, 22, 
23, 24, 25, 26, 27, 28, and 29. Our reviewer says that the extractions are not medically necessary. Our 
physician reviewer found the need for surgical extractions (D7210) of teeth #'s 20, 21, 22, 23, 24, 25, 26, 27, 
28, and 29 which involves removal of bone and/or sectioning of teeth has not been demonstrated by the 
documentation provided. 
 
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 extractions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve extractions (D7210) of teeth #'s 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea 5 day inpatient video Electroencephalogram (EEG) (95720 x5).You asked the Plan to pre-approvethe inpatient video EEG. You say that the inpatient EEG is medically necessary.The Plan denied your request. The Plan says criteria for coverage has not been met.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 inpatient video EEG. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the plan to proceed with an inpatient EEG prior to a review of the results of an ambulatory study appears to be premature in nature. It would otherwise be more appropriate to proceed with an ambulatory EEG, review the results of said study and then consider if further evaluation is necessary. An Ambulatory EEG may be able to capture clinical information which would then eliminate the need for inpatient EEG.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 inpatient video EEG have not been met.Therefore, we decided that the Plan does not have to pre-approvea 5 day inpatient video Electroencephalogram (EEG) (95720 x5).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair transit accessory (K0108). 
 
You asked the Plan to pre-approve the wheelchair transit accessory. You say that the accessory is medically 
necessary. The Plan denied your request. The Plan says this item is to allow use of the DME outside the home, 
and is therefore non-covered. 
 
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. 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-approve a wheelchair transit accessory (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for 
the enrollee. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above 
criteria have been met. 
 
We looked at the file and Medicare rules. The file indicates the enrollee is not testing his blood glucose four or 
more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that you want to continue 
therapy because it helps your daily life. The Plan denied your request. The Plan says additional visits are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that you have had prior therapy for this condition and 
were educated in an independent exercise program. Our reviewer says that the unique skills of a professional 
therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that your partial was broken when you were at 
the hospital. The Plan denied your request. The Plan says partial dentures are covered once every 5 plan years. 
The Plan says that the frequency limit has been reached. The Plan also says that repair to the existing partial 
denture is a covered service and should be discussed with your dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and a partial denture is a covered 
service, the frequency limit of once every 5 plan years has been reached. The record shows the Plan paid for a 
lower partial denture that you received on March 6, 2020. Therefore, we decided that the Plan does not have to 
pre-approve a lower partial denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that this is medically necessary. The Plan 
denied your request. The Plan says coverage of this medication is the responsibility of your prescription drug 
plan. 
 
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 Repatha Sureclick.  
 
Benefits for Repatha Sureclick 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre continuous glucose monitor sensors. 
 
You asked the Plan to pre-approve FreeStyle Libre continuous glucose monitor sensors. You say that this is 
critical for your health. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices and supplies are covered when the 
beneficiary is insulin-treated with three or more daily injections of insulin and is testing their glucose levels 
four or more times a day. 
 
We looked at the file and Medicare rules. The records do not show that you are insulin-treated with three or 
more daily injections of insulin and testing your glucose levels four or more times a day. Based on this 
information, we decided that Medicare rules for coverage of FreeStyle Libre continuous glucose monitor 
sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre 
continuous glucose monitor sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Percutaneous Left Atrial Appendage Closure (LAAC) 
device (33340). 
 
You asked the Plan to pre-approve the LAAC device. You say that the device is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that The Centers for Medicare & Medicaid Services 
(CMS) covers percutaneous LAAC for non-valvular atrial fibrillation (NVAF) through Coverage with 
Evidence Development (CED).  
 
We looked at the file and Medicare rules. This item is only covered in the context of CED. The record shows 
no enrollment in an approve clinical trial or other context that would allow coverage. Based on this 
information, we decided that Medicare rules for coverage of the LAAC device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Percutaneous Left Atrial Appendage Closure (LAAC) 
device (33340).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that you were denied a replacement denture. You 
say that the dentist must have used an incorrect code because you never received any replacement dentures. 
You also say that you did receive a hot, hard lining. The Plan denied your request. The Plan says dentures are 
covered once every 5 plan years. The Plan also says that the frequency limit has been reached. 
 
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 and dentures are a covered service, the 
frequency limit of once every 5 plan years has been reached. The record shows that the Plan paid for a 
complete upper denture that you received on September 18, 2017. Additionally, if the denture you do have 
needs adjustment or repair this is a covered benefit. Therefore, we decided that the Plan does not have to pre-
approve a complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power elevating leg rests (E1012) and an electrical connection (E2311).

You asked the Plan to pre-approve power elevating leg rests and an electrical connection. You say that the enrollee needs these items. The Plan denied your request. The Plan says these items are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that power elevating leg rests and electrical connections are covered when medically necessary according to the above guidelines. The Plan follows Medicare rules. Medicare rules say that power elevating leg rests and electrical connections are covered when medically necessary according to the above guidelines.

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 power elevating leg rests and an electrical connection. Our reviewer says that the criteria for coverage of the requested items have not been met. Our physician reviewer found an electrical connection (E2311)  and the power elevating leg rests  (E1012) are  not medically necessary as the patient does not need to control more than 1 power option through the drive control and and the patient's strength and functional ability would allow the patient to control the powered option with its own switch. There is no evidence of the inability to perform a functional weight shift, use intermittent catheterization or need powered seating to control spasticity. Furthermore, there is  no evidence of a cast/brace, significant leg edema, or a need for a reclining back 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 power elevating leg rests and an electrical connection have not been met. Therefore, we decided that the Plan does not have to pre-approve power elevating leg rests (E1012) and an electrical connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional acupuncture visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case. 
 
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 additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found the 
notes do not include any assessment of pain or of functional improvement.  Therefore, the request for 
additional treatments cannot be supported at this time. The requested treatments are deemed not medically 
reasonable or necessary due to this lack of documentation. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight additional acupuncture visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mouth guard. 
 
You asked the Plan to pre-approve the mouth guard. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this item is not covered. 
 
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 mouth guard have not been met. We reviewed the records and 
they show pain in the jaw muscles and joint (articular disc disorder of bilateral temporomandibular joint or 
TMJ). The enrollee is having face pain and headaches. Oral occlusal appliances used to treat TMJ disorders are 
considered to be dental devices and will be denied as non-covered. Claims for oral occlusal appliances used to 
treat TMJ disorders should not be submitted to the DME MACs. Therefore, we decided that the Plan does not 
have to pre-approve the mouth guard.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulsed radiofrequency of the occipital nerve. 
 
You asked the Plan to pre-approve pulsed radiofrequency of the occipital nerve (64999). You say that the 
enrollee needs this procedure for pain management. The Plan denied your request. The Plan says the request 
does not meet Medicare's guidelines for medical necessity. 
 
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 pulsed radiofrequency of the occipital 
nerve (64999). Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is an experimental/ investigational therapy. Pulsed RF 
is considered experimental/ investigational and there are no large randomized trials with long term follow-up.  
Therefore, the request is considered not medically reasonable or 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 pulsed radiofrequency of the occipital nerve (64999) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve pulsed radiofrequency of the occipital nerve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing in all quadrants. 
 
You asked the Plan to pre-approve periodontal scaling and root planing in all quadrants. The Plan denied your 
request. The Plan says the criteria for coverage has not been met. 
 
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 periodontal 
scaling and root planing in all quadrants 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 periodontal scaling and root planing in 
all quadrants. Our physician reviewer found that the radiographs were not of diagnostic quality and the 
periodontal charting was not legible. Our reviewer says that the documentation provided did not show that the 
criteria for coverage for scaling and root planing have been met. 
 
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 periodontal scaling and root planing in all quadrants have not been met. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing in all 
quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). The Plan denied your request. The Plan says the 
service 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 pre-approve core 
buildup (D2950).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that the doctor has requested 
more treatment because it is taking longer to heal. The Plan denied your request. The Plan says additional visits 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 12 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that you have had extensive therapy for 
this condition and should be able to transition to a home exercise program. Our reviewer says that the unique 
skills of a professional therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 12 additional physical therapy visits.