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

 
We decided that the Plan does not have to pre-approve exome sequence analysis testing. 
 
You asked the Plan to pre-approve these services. You say that your doctor has been investigating the cause of 
symptoms related to mitochondrial myopathy. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that exome sequence analysis 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 records show that you have a 
diagnosis of unspecified metabolic disorder. You were evaluated on June 9, 2020 regarding fatigue and muscle 
weakness (myopathy). A muscle biopsy showed muscle thinning. The requested exome sequence analysis 
testing would not directly impact the treatment or management of your condition and is 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 exome sequence analysis testing.
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 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 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 submitted records show that you were admitted to the hospital on September 3, 
2020 and were discharged home on September 8, 2020. You have no complex medical, nursing, or 
rehabilitation needs that require the intensity of services provided at an IRF. Specifically, you do not need 15 
hours per week of rehabilitative services and regular physician evaluation. You may benefit from further 
therapy but do not require an intensive therapy program 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network durable medical 
equipment provider. 
 
You asked the Plan to pre-approve these services. You say that you dislike the approved company. The Plan 
denied your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network durable medical equipment provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve night train drive wheel accent color for a power 
wheelchair (PWC). 
 
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 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. Therefore, we 
decided that the Plan does not have to pre-approve night train drive wheel accent color for a power wheelchair 
(PWC).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the extraction (D7210) for tooth # 29. We decided that the Plan 
does not have to pre-approve the porcelain/ceramic crown (D2740) for tooth #27, porcelain fused to high noble 
metal crown (D2750) for tooth #29 and residual root removal (D7250) for tooth #'s 2 and 13.  
 
You asked the Plan to pre-approve the porcelain/ceramic crown (D2740) for tooth #27, porcelain fused to high 
noble metal crown (D2750) for tooth #29, extraction (D7210) for tooth # 29 and residual root removal (D7250) 
for tooth #'s 2 and 13. The Plan says that the services are not medically necessary. 
 
We decided that the Plan has to pre-approve the extraction (D7210) for tooth # 29.  
 
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 the extraction for tooth #29. Our reviewer says that the 
criteria for coverage has been met. Our physician reviewer found that the coronal structure has significant 
breakdown and root removal would involve a surgical procedure. Therefore, we decided that the Plan has to 
pre-approve the extraction (D7210) for tooth # 29.  
 
We also decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740) for 
tooth #27, porcelain fused to high noble metal crown (D2750) for tooth #29 and residual root removal 
(D7250) for tooth #'s 2 and 13. 
 
Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found that the crown 
for tooth #29 is not necessary because it is being extracted. Our physician reviewer found that the residual root 
removal for tooth #2 cannot be determined to be medically necessary due to poor diagnostic quality of the x-
ray. Our physician reviewer found that a different code would be more appropriate for tooth #13. Our physician 
reviewer found that the crown for tooth #27 cannot be determined to be medically necessary due to poor 
diagnostic quality of the x-ray. 
 
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 porcelain/ceramic crown (D2740) for tooth #27, porcelain fused to high 
noble metal crown (D2750) for tooth #29 and residual root removal (D7250) for tooth #'s 2 and 13 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the porcelain/ceramic crown 
(D2740) for tooth #27, porcelain fused to high noble metal crown (D2750) for tooth #29 and residual root 
removal (D7250) for tooth #'s 2 and 13.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT Code 64635) 
and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or 
CT); lumbar or sacral, each additional facet joint (CPT Code 64636). 
 
You asked the Plan to pre-approve the services. You say that this is going to help with pain. The Plan denied 
your request. The Plan says the Medicare rules have not been 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 the services. Our physician reviewer 
found the proposed RFA includes a level of prior surgery. You only achieved 60-70% pain relief which is 
below the 80% threshold to be considered a successful diagnostic block. Therefore, the request is 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, single facet joint (CPT Code 64635) and destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional 
facet joint (CPT Code 64636).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation, three extractions, and each subsequent 
15 minute increment of deep sedation/general anesthesia to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the consultation, extractions, and deep sedation/general anesthesia. You say 
that you have 3 infected teeth, and per your dentist, need them to be removed by an oral surgeon. The Plan 
denied your request. The Plan says dental services provided by an oral surgeon are not covered. 
 
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, the requested items or services are not 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation, three extractions, and each subsequent 15 minute 
increment of deep sedation/general anesthesia to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar decompression and fusion procedure. 
 
You asked the Plan to pre-approve the spinal surgery. You say that surgery is warranted at this time as it is not 
likely to be alleviated by therapy based on past experience. The Plan denied your request. The Plan says 
without evidence that a new trial of therapy will not cure the enrollee's condition, surgery is not warranted. 
 
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 spinal surgery. Our reviewer says 
that the requested spinal surgery is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of lumbar pain requiring multiple ED pain management 
visits in the recent months. She has a prior history of surgical management but her condition is now 
progressing. She has been taking oral medications and has tried therapy in the past which was not helpful. 
 
The medical records do not show that the patient has had an adequate trial and failure of conservative measures 
to include a recent and adequate trial of PT. Surgery not needed at this time. More conservative measures are 
needed. 
 
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 spinal surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lumbar decompression and fusion procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to provide coverage for inpatient admission for knee surgery for the enrollee. 
 
You asked the Plan to provide coverage for inpatient admission. You say that inpatient admission is medically 
necessary due to other health conditions present in the enrollee. The Plan denied your request. The Plan says 
that while the knee surgery was approved, inpatient admission was not. 
 
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 provide coverage for inpatient admission. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found that due to the enrollee's age and comorbidities, inpatient hospitalization is 
reasonable and indicated. The past medical history of this enrollee is well documented in the notes provided. 
Inpatient coverage criteria are 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 inpatient admission have been met. Therefore, 
we decided that the Plan has to provide coverage for inpatient admission for knee surgery 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: 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 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 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 submitted records show that you were admitted to the hospital for left hip 
surgery. Your medical problems are currently stable and you have no complex nursing or rehabilitation needs. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive therapy program 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve enteral nutrition therapy. 
 
You asked the Plan to pre-approve the enteral nutrition therapy. You say that the enrollee has throat cancer and 
significant radiation damage to his pharnyx. You say that the enrollee gets nutrition entirely from his peg tub, 
because he is unable to swallow food of any sort and has been getting his nutrition this way for several years. 
You say that the enrollee is on a combination of Isosource and Boost high calorie. You say that the enrollee is 
not currently getting his full nutrition without the Isosource and will not be able to maintain his already low 
weight without the Isosource. The Plan denied your request. The Plan says that the enrollee has not met the 
criteria for coverage. The Plan says that there is no clinical assessment of the enrollee with an evaluation of 
nutrition. albumin, transferrin, hematocrit, clinical findings, etc. within 30 days prior to certifying or re-
certifying the need for enteral nutrition. 
 
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 the enteral nutrition therapy. Our 
reviewer says that enteral nutrition therapy is considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is noted to have a history of oral pharyngeal cancer, which has resulted 
in the need for a permanent feeding tube.  The health plan argues that the LCD requires a clinical assessment 
of the patient with an evaluation of nutrition, albumin, transferrin, hematocrit, clinical findings, etc. within 30 
days prior to certifying or re-certifying the need for the enteral nutrition.  Our physician reviewer was unable 
to identify such verbiage within the LCD.  While the office record could more clearly note a diagnosis of 
dysphagia and the ongoing need for enteral feedings, the overall documentation is sufficient to support the 
diagnosis and need.  Therefore, the requested ongoing enteral nutrition is shown to be medically necessary and 
reasonable. 
 
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 enteral nutrition therapy have been met. Therefore, we decided that the Plan 
has to pre-approve enteral nutrition therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement insulin pump and Dexcom 6 continuous 
glucose monitor (CGM) and CGM supplies. 
 
You asked the Plan to pre-approve a replacement insulin pump and continuous glucose monitor. You say that 
this equipment is medically necessary. The Plan denied your request. The Plan says your insulin pump is less 
than 5 years old and you do not meet all of the required criteria for a continuous glucose monitor.  
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for a continuous glucose monitor. 
Medicare does not replace equipment less than 5 years old unless it in nonfunctional and/or cannot be repaired.   
Based on the records provided, you do not meet the required criteria for either of the items you requested. The 
records received indicate that you do not check your blood sugars at least 4 times per day or that you frequently 
adjust your insulin doses based on your blood sugar readings. Medicare coverage criteria are not met. 
Therefore, we decided that the Plan does not have to pre-approve a replacement insulin pump and Dexcom 6 
continuous glucose monitor (CGM) and CGM supplies.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that you still need assistance to get up or walk 
and you cannot go home and care for yourself. You say you are extremely scared and believe that you need to 
be put back on the original medication to help recovery. You say that you never denied physical therapy. The 
Plan denied your request. The Plan says you do not meet Medicare criteria for SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing 
perspective, you received oral medications. You had stable vital signs and you were treated for C. difficile 
colitis. Regarding rehabilitation services, you received physical therapy (PT), speech therapy (ST) and 
occupational (OT) in the acute hospital. You were at a standby assist to independent level with functional 
mobility including gait to 40 feet with a rolling walker. You required varying assist with activities of daily 
living and you tolerated a pureed diet and thin liquids. There are no identifiable skilled nursing service needs. 
There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a 
daily basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.