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

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750) for tooth #'s 11 & 14 and 
pontics (D6240) for tooth #'s 12 & 13. 
 
You asked the Plan to pre-approve the retainer crowns and pontics. You say that a bridge is needed for tooth #'s 
11, 12, 13, and 14, to replace tooth #'s 12 and 13. The Plan denied your request. The Plan says the documents 
fail to demonstrate a specific medical condition that would preclude the use of a removable partial denture. 
 
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 retainer 
crowns and pontics 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 retainer crowns and pontics. Our 
reviewer says that the retainer crowns and pontics are not medically necessary. Our physician reviewer found 
the medical records do not indicate any medical condition that would preclude the use of a removable appliance 
by the enrollee. Our reviewer found that fixed prosthetic appliances are not generally covered under the Plan, 
with the need for prosthodontics being addressed with the use of removable appliances. Policy manual criteria 
requires documented medical or neurological deficits that would make the use of a removable appliance 
unreasonable for the member before considering alternatives. Our physician reviewer also found that given the 
provided medical records, and lack of any documentation of a physical or neurological deficit, the request for 
the two abutments and two pontics are not medically necessary, as a removable partial denture is a reasonable 
alternative treatment. 
 
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 retainer crowns and pontics have not been met. Therefore, we decided that 
the Plan does not have to pre-approve retainer crowns (D6750) for tooth #'s 11 & 14 and pontics (D6240) for 
tooth #'s 12 & 13.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not 
require transfer to the LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include surveillance laboratory studies, hemodialysis, wound 
care, close fluid balance, and therapy services. The documentation does not support that the enrollee in this 
case requires services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. There are no required medical services identified that are available at the LTACH, that are not 
available at the current health care setting being offered by the health plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Metoprolol Tartrate and Nitroglycerin provided on 
March 23, 2020. 
 
You asked the Plan to pay for the Metoprolol Tartrate and Nitroglycerin. You say that you do not have money 
for this denial. The Plan denied your request. The Plan says these drugs are self-administered drugs and not 
covered by Part B. 
 
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 pay for the Metoprolol Tartrate and 
Nitroglycerin provided on March 23, 2020.  
 
Benefits for the Metoprolol Tartrate and Nitroglycerin 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
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 self-administered drugs are not covered. 
 
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 Eliquis.  
 
Benefits for these services 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's request is not medically necessary because records show 
the enrollee's chronic conditions are stable and do not require frequent rehabilitation physician management. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While there is a documented need for physical and occupational therapy, the medical records do not 
support the need for an intensive rehabilitation program and services can be safely and effectively provided at a 
lower level of care. There is not a reasonable expectation that this patient will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve a power seat elevation system. 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 a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on 
March 18, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan. 
 
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. Your EOC states, "bitewing x-rays are limited to two limes in a 
Calendar Year when provided to enrollees under age 18 and one time each Calendar Year for enrollees age 18 
and over. Bitewings of any type are disallowed within 12 months of a full mouth series unless warranted by 
special circumstances." Therefore, we decided that the Plan does not have to pay for bitewings - four 
radiographic images (D0274) provided on March 18, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While there is a documented need for physical and occupational therapy, the medical records do not support the 
need for an intensive rehabilitation program and services can be safely and effectively provided at a lower level 
of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF 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 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 a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. The Plan denied your request. The Plan says that that 
the information sent in does not show that your present power device is worn out or does not meet your needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided evidence that your previous power wheelchair is less 
than five years old. Therefore, we decided that the Plan has to pre-approve a power wheelchair.  
 
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 nerve block. 
 
You asked the Plan to pre-approve a nerve block. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services 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 a nerve block. 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 persistent right knee pain. The enrollee reports constant, aching pain, located to 
anterolateral knee joint. Pain is aggravated with standing/walking with an 8 out of 10 severity. The enrollee has 
tried physical therapy and is on voltaren prn as well as bursa injections. The requested service is an 
experimental/ investigational procedure is the setting of post total knee replacement and is the subject of on-
going clinical trials.  Therefore, the enrollee does not meet criteria for the requested 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 a nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deep sedation/general anesthesia - first 15 minutes (D9222) 
provided on March 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan. 
 
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. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pay for deep sedation/general anesthesia - 
first 15 minutes (D9222) provided on March 4, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan (78815). 
 
You asked the Plan to pre-approve a PET scan. You say that this is necessary for staging. The Plan denied your 
request. The Plan says that repeat PET scans are not supported for treatment planning. 
 
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 a PET scan. Our reviewer says that the 
requested PET scan is medically necessary. Our physician reviewer found the enrollee has a non-small cell 
lung cancer. She had a PET in April 2020 but a CT in June 2020 showed suggestion of a progression in her 
hilar nodes. A PET scan is necessary to restage her and reevaluate the hilar nodes. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan (78815).  
 
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a bilateral breast ultrasound. 
 
You asked the Plan to pre-approve a bilateral breast ultrasound. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested services are not 
medically necessary. 
 
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 a bilateral breast ultrasound. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is at high risk for breast cancer as sister (a first degree relative) has 
history of breast cancer. Ultrasound has been shown superior by a study in the journal Nature in breast cancer 
screening in high risk women. With a family history of breast cancer in a first degree relative this enrollee 
would be considered high risk. The test is reasonable and medically necessary in the screening of a high risk 
enrollee. Therefore, the enrollee meets criteria for the requested 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 a bilateral breast ultrasound have been met. Therefore, we decided that the Plan 
has to pre-approve a bilateral breast ultrasound.  
 
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's therapy needs can continue to be provided at a lower 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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require, or to be able to perform, 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. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise 
specified (K0108) and power wheelchair accessory, attendant control, proportional, including all related 
electronics and fixed mounting hardware (E2331), for the enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not medically necessary. 
 
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 DME have not been met.  Review of the file shows that power 
wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting 
hardware (E2331) is denied because the Plan has already approved a member control. Therefore, the attendant 
control is not covered. 
 
Furthermore, you are requesting a Smart Check Device (wheelchair component or accessory, not otherwise 
specified (K0108)). Smart Check is a cushion feedback system that is intended to assist the user 
by saving an inflation range during cushion setup. During subsequent inflation level checks, Smart Check is 
intended to indicate whether adjustments are needed to remain in the saved range. This device does not serve a 
medical purpose and is for convenience only. Therefore, we decided that the Plan does not have to pre-approve 
wheelchair component or accessory, not otherwise specified (K0108) and power wheelchair accessory, 
attendant control, proportional, including all related electronics and fixed mounting hardware (E2331), for the 
enrollee.