Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants. 
 
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. 
 
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 
dental implants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services you received from January 7, 2020, 
to May 26, 2020. 
 
You asked the Plan to pay for the acupuncture services. You say that this has helped with your pain. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the documentation provided does not show that the 
acupuncture services were provided for chronic low back pain. Medical records from the non-contract provider 
were not submitted. Without records, it cannot be determined that Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for the acupuncture services you received from 
January 7, 2020, to May 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mouth prosthesis from a non-Medicare-participating 
provider. 
 
You asked the Plan to pre-approve the services. You say that this provider did your prosthesis, and can do the 
repairs. The Plan denied your request. The Plan says this provider does not participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
The provider for this prosthesis does not participate in Medicare, and is not eligible for payment. 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 a mouth prosthesis from a non-Medicare-participating 
provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not support that the diagnostic criteria have been met. 
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found per the neurology notes 
the differential diagnosis for this patient is Alzheimer Dementia versus Lewy Body Dementia.  Per CMS 
guidelines the NCD criteria specify that PET scan of the brain is only approved when there is a differential 
between Alzheimer Dementia and Frontal Temporal Dementia and specifically when there is a question of 
Lewy Body PET scan is considered investigational and NOT covered.  Since the records indicate no clinical 
suspicion of FTD and there is a question of Lewy Body Dementia the scan will not be covered per CMS 
guidelines. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PET scan of the brain for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a total hysterectomy. 
 
You asked the Plan to pre-approve the hysterectomy. You say that you do not want to try other treatments since 
hysterectomy will be more effective in treating your issue. The Plan denied your request. The Plan says that it 
is felt that endometrial ablation would be reasonable, but that the records do not support the need for total 
hysterectomy. 
 
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 hysterectomy. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this is a 49-year-old female with heavy menstrual bleeding/abnormal uterine bleeding. The 
patient is currently taking 15 mg of Aygestin daily and the bleeding is not controlled. An endometrial biopsy 
was benign showing progestin effect. A pelvic ultrasound showed possible adenomyosis. Per patient report she 
is anemia on iron daily. She has unpredictable bleeding that is affecting her quality of life. She was not 
interested in a levonorgestrel IUD or an endometrial ablation. She desires hysterectomy for definitive treatment 
of abnormal uterine bleeding. 
 
A hysterectomy is medically reasonable and necessary for the treatment of abnormal uterine bleeding for this 
patient.  Hysterectomy is an option for definitive treatment that is accepted.  The patient is taking a high dose 
of progestin and still her bleeding is not controlled.  There is no reason to require her to try an endometrial 
ablation first if she desires definitive therapy with a hysterectomy.  There is evidence of possible adenomyosis 
on the ultrasound which is a potential cause for the abnormal uterine bleeding.  Hysterectomy is a medically 
reasonable treatment for this as long as the patient has been counseled regarding the risks/benefits and 
alternatives. 
 
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 hysterectomy have been met. Therefore, we decided that the Plan has to pre-
approve a total hysterectomy.  
 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee must be receiving skilled nursing care on an intermittent basis, or physical 
therapy/speech therapy/occupational therapy. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found there is no 
documentation that the enrollee is receiving any skilled nursing or therapy services. Based on the medical 
records provided there is no documentation that the home health aide services are reasonable and necessary to 
the treatment of the enrollee's illness or injury by the skilled professional staff as the enrollee must be receiving 
skilled nursing care on an intermittent basis, or physical therapy or speech therapy or occupational therapy to 
qualify for home health aide services. 
 
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 home health aide services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show the results of an examination done by the doctor.

The Plan must follow Medicare rules. Medicare rules say that facet joint injections are covered in the absence of radicular pain. 

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 reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar radiculopathy as well as facet arthropasthy. 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cerebral perfusion analysis using computed tomography 
provided on February 19, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says Medicare 
lists the service as not reasonable and necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this physician's review, the file, and Medicare rules. The service at issue is not covered by 
Medicare or the enrollee's plan. Therefore, we decided that the Plan does not have to pay for the cerebral 
perfusion analysis using computed tomography provided on February 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Visudyne. 
 
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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has choroidal nevus and 
exudative retinal detachment. The case file contains an ophthalmic ultrasound report. The documentation is 
insufficient to demonstrate that Visudyne is medically reasonable and necessary and safe and effective for the 
enrollee in this case. 
 
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 Visudyne.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scans of the soft tissues of the neck. 
 
You asked the Plan to pre-approve the neck CT scan. You say that it is felt that surgery is the best option rather 
than biopsy and the imaging is needed to plan for the procedure. The Plan denied your request. The Plan says 
that there is no need for surgical removal so CT imaging is not warranted. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 neck CT scan. Our reviewer says 
that the requested imaging appears to be medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a female with a history of multinodular goiter with the largest nodules being 
4.7cm. The treating physician documents that biopsy is not feasible in this case and that surgical removal is the 
better option to remove the nodule and confirm pathology. The CT scan is requested to aid with surgical 
planning. As this imaging is requested explicitly to evaluate the enrollee for surgery and for preoperative 
planning, it is considered a medical necessity. 
 
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 neck CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scans of the soft tissues of the neck.  
 
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 a referral to a urology specialist. 
 
You asked the Plan to pre-approve the referral. You say that you are at risk for infection, because the previous 
doctor was not able to cure incontinence. The Plan denied your request. The Plan says a urologist consultation 
is not pertinent to your condition. 
 
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 referral. Our reviewer says that the 
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is documentation of fecal incontinence, but no documentation of a urologic problem. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral to a urology specialist.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a partial colectomy (44140) provided on December 5, 2019. 
 
You asked the Plan to pay for the partial colectomy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
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 44140 is colectomy, partial; with anastomosis. 
 
We asked our coder 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 partial colectomy. Our reviewer says that CPT code 
44140 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative 
report indicates that a hemicolectomy and loop ileostomy was performed, and does not support a partial 
coloectomy with anastomosis. 
 
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 partial colectomy have not been met. Therefore, we decided that the Plan 
does not have to pay for a partial colectomy (44140) provided on December 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has been in custodial care since 10/22/20. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require ongoing 
skilled nursing services or skilled therapy after 10/21/20. The specialized skill, knowledge and judgment of a 
skilled professional nurse or qualified therapist is not required to safely and effectively provide medically 
necessary and reasonable treatment. Based on the medical records provided this enrollee does not require the 
services on an inpatient basis, in a skilled nursing facility setting after 10/21/2020. Services in the long-term 
care facility on a part time basis or in the home with home health services appears appropriate in this case. 
 
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 continued admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four monitoring (95999) provided on March 9, 
2020. 
 
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation indicates that train of 
four testing/monitoring was performed which does not meet the CMS guidelines of CPT code 95999. 
 
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 95999 is unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring is considered 
integral to the primary neuromonitoring service and is not separately reimbursable. Based on this information, 
we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we 
decided that the Plan does not have to pay for the train of four monitoring (95999) provided on March 9, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a thyroidectomy with an out-of-network 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider is not 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 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 for a thyroidectomy with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home-delivered meals. 
 
You asked the Plan to pre-approve the meals. You say that the enrollee's dementia has gotten worse, and it 
would be dangerous for him to use the oven. The Plan denied your request. The Plan says this is not a covered 
benefit for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
Home-delivered meals are not considered a medical item or service, so they cannot be considered medically 
necessary. Based on this information, we decided that Medicare rules for coverage of the meals have not been 
met. Therefore, we decided that the Plan does not have to pre-approve home-delivered meals.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Logisticare mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan 
denied your request. The Plan says the benefit only allows 50 miles. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation when the one-way trip does not exceed 50 miles one-way. 
 
The requested trip is 54 miles one-way - 4 miles over the limit. Based on this information, we decided that the 
Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional Logisticare mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment supported removable lower denture 
(D6111). 
 
You asked the Plan to pre-approve the dental item. You say that your dentist has determined that implants are 
medically necessary. You also say that your physical health is being affected by your lack of teeth and inability 
to chew. The Plan denied your request. The Plan says abutment supported removable lower denture is not listed 
as a covered service. The Plan also says any services not listed 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 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 Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pre-approve an abutment supported 
removable lower denture (D6111).