Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above 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 a seat lift mechanism. Our reviewer 
says that the documentation does not support that the requested seat lift mechanism is medically reasonable or 
necessary. Our physician reviewer found you have a diagnosis of other intervertebral disc degeneration, lumbar 
region. The documentation does not support that you have severe arthritis of the hip; and/or a neuromuscular 
disease. The documentation does not support that the requested seat lift is likely to effect improvement in your 
condition; or arrest or retard deterioration in your condition. Therefore, you do not meet criteria for the 
requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that you were diagnosed with cancer. You say that 
you were started on chemotherapy and radiation. You say that you were not able to have dental work done 
during that time. You also say that you are retired and do not have coverage. The Plan denied your request. The 
Plan says the requested partial denture is dental in nature. The Plan says routine dental items and services are 
not covered. The Plan also says any excluded service rendered will be the enrollee's responsibility. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an upper partial 
denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of an oxygen concentrator. 
 
You asked the Plan to pre-approve oxygen equipment. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of authorization for this equipment is correct, because the 
enrollee does not meet the Medicare criteria for continued oxygen use. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 oxygen equipment. Our reviewer says 
that the enrollee does not meet the Medicare criteria for continued use of oxygen equipment. Our physician 
reviewer found the records show one oxygen saturation measurement of 98% breathing room air. There are no 
oxygen measurements that indicate a need for supplemental oxygen. Therefore, home oxygen is not 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 oxygen equipment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued use of an oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept Procedure. 
 
You asked the Plan to pre-approve an Intracept Procedure. You say that this procedure is done within the 
vertebral body to address vertebrogenic pain. The Plan denied your request. The Plan says the Intracept 
procedure is considered experimental and 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 an Intracept 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 still considered an experimental/ investigational procedure because of the 
limited number of studies that have been published. Therefore, the requested procedure is deemed 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 an Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept Procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a type of equipment that is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have topre-approvepsychotherapy services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvepsychotherapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.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-approvepsychotherapy services to be provided by an out of network (OON) provider.We note that the plan has approved a three month period of services to be provided by this provider for the enrollee while the enrollee searches for an in-network provider to receive these services from.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain fused to noble metal crown (D2750) for tooth # 9. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee needs a few crowns due to 
decay forming under them and causing pain. The Plan denied your request. The Plan says that the requested 
documentation was not provided in the proper time frame. 
 
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 dental 
service 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 dental service. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the submitted documentation indicates 
significant coronal breakdown due to caries in tooth # 9. Therefore, the reviewer found that a crown restoration 
to return tooth # 9 to normal function is medically reasonable and necessary. 
 
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 dental service have been met. Therefore, we decided that the Plan has to 
pre-approve a porcelain fused to noble metal crown (D2750) for tooth # 9.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injection of a substance in the neck or upper back using 
imaging/guidance or detailed pictures to diagnose or treat pain (64490). 
 
You asked the Plan to pre-approve facet injection 64490. You say that this procedure is medically necessary 
because the enrollee has severe left upper cervical pain and  associated occipital headache and CT evidence of 
moderate C1-2 joint arthropathy. The Plan denied your request. The Plan says the requested service is not 
medically necessary and the enrollee does not meet the Medicare criteria. 
 
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 facet injection 64490. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found although there is radiographic evidence of C1-2 facet arthropathy, there is no 
submitted clinical evidence or physical examination findings of painful provocative cervical spine facet 
loading. Also given the dens fracture, it can be said that this non-facet pathology is not the source of patient's 
cervical pain because this is a previous fracture that is currently clinically dormant. And deemed that high 
cervical spinal level diagnostic injection at C1-C2 (64490) is not in accordance with evidence-based and 
scientifically validated published medical literature.  In addition, this enrolllee has not received and failed 
adequate pre-procedure conservative care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injection 64490 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Injection of a substance in the neck or upper back using imaging/guidance or 
detailed pictures to diagnose or treat pain (64490).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two further podiatry visits. 
 
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 six visits are approved and two further are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted podiatry records do not 
show any circumstance or situation for which you would need to be seen for two further visits. The approved 
six visits appear to be within normal limits, safe, effective, and the standard of care for your condition. Two 
further visits are 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 two further podiatry visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed and a manual wheelchair for 
the enrollee. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says these items are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
Medicare rules say that a manual wheelchair is covered if there is a mobility limitation that limits MRADLs, 
and that limitation cannot be resolved with an appropriately-fitted cane or walker. 
 
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 items. Our reviewer says that the 
requested items are not medically reasonable or necessary. Our physician reviewer found there is no evidence 
that the enrollee's condition requires special attachments that cannot be fixed and used on an ordinary bed. 
There is no documentation provided which states why a standard bed could not be used. The enrollee's 
condition does not require positioning of the body in ways not feasible on an ordinary bed. There is no mention 
of requiring frequent or immediate changes in body position. For the wheelchair, there is no documentation that 
the enrollee's home will be able to manage and accommodate a 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a semi-electric hospital bed and a manual wheelchair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950). 
 
You asked the Plan to pre-approve the dental service. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service. The 
Plan also says if a dental item or service is not listed in the benefit chart or listed with NC, then it is not 
covered. 
 
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. The Dental Handbook clearly states if a dental item or service is not 
listed in the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan does not 
have to pre-approve core build up (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of spinal code stimulators (63650, L8680). 
 
You asked the Plan to pre-approve the insertion of spinal code stimulators. You say that this is medically 
necessary. The Plan denied your request. The Plan says there is no documentation of surgical intervention. 
 
The Plan follows Medicare rules. Medicare rules say that the implantation of the stimulator is to be used only 
as a late resort for patients with chronic intractable pain for whom other treatment modalities (pharmacological, 
surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, or are judged to 
be unsuitable or contraindicated for the given patient. 
 
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 insertion of spinal code stimulators. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the patient 
has had an extensive work up but has not had a surgical consult.  Therefore, at this point, the request is deemed 
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 insertion of spinal code stimulators have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of spinal code stimulators (63650, L8680).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says needs can be met at a lower level of care, such as at a skilled nursing level of care. 
 
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 does not require the intensity of services provided at an IRF. Specifically, the 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
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 enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when the enrollee 
is insulin-treated with multiple (three or more) daily injections of insulin and meets other criteria. 
 
We looked at the file and Medicare rules. The file shows that the enrollee is not insulin-treated. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS placement. You say that the records provided support the 
medical need for a CardioMEMS system. The Plan denied your request. The Plan says the information does not 
show that the requested CardioMEMS system is medically necessary. The Plan says that the research has not 
shown that this is as good or better than other treatments or procedures. 
 
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 CardioMEMS placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found therapy change based on data obtained from a CardioMEMS device has 
been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. 
Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not 
met since the device should still be considered experimental or investigational. 
 
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 CardioMEMS placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of a CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelower back implants, percutaneous epidural implantation of neurostimulator electrode array (63650) Fluoroscopic guidance (77003) Electronic analysis of implanted neurostimulator pulse generator/transmitter (95972).You asked the Plan to pre-approvea spinal cord neurostimulator trial. You say that authorization was denied because psychological clearance was not submitted. Please see attached, all clinicals. Please expedite. The enrollee is scheduled for 9/29/20 procedure.The Plan denied your request. The Plan says this enrollee does not meet the Medicare criteria for the requested services. 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 a spinal cord neurostimulator trial. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not had a psychological evaluation. Therefore, he does not meet the criteria of the NCD. The requested procedure is not medically reasonable or necessary at this point. Fluoroscopy is intrinsic to the procedure and is not separately billable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal cord neurostimulator trial have not been met.Therefore, we decided that the Plan does not have to pre-approvelower back implants, percutaneous epidural implantation of neurostimulator electrode array (63650) Fluoroscopic guidance (77003) Electronic analysis of implanted neurostimulator pulse generator/transmitter (95972).