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

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).

You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.



We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the face/neck.
You asked the Plan to pre-approve MRI. You say that you underwent an esophagram in 2017 but are still
having difficulty swallowing. The Plan denied your request. The Plan says that the denial of authorization for
this service is correct, because the records do not show the results of a swallowing test.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that you meet
the Medicare criteria for the requested MRI. Our physician reviewer found you had a swallowing test and it
was negative. Your symptoms are ongoing, so this test is medically reasonable and 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve
Magnetic Resonance Imaging (MRI) of the face/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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest.
You asked the Plan to pre-approve these services. You say that the CT scan is standard of care. The Plan
denied your request. The Plan says that the services are not medically necessary.
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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee has a history of lung cancer
and continues to smoke. Surveillance CT scans have been ordered. The enrollee is an ongoing smoker with
very high risk for recurrence or new cancer; therefore, the CT scan is reasonable and 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 been met. Therefore, we decided that the Plan has to preapprove
a computed tomography (CT) scan of the chest.
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 8 & 9 and a prefabricated 
post and core in addition to crown (D2954) for tooth #8. 
 
You asked the Plan to pre-approve the crowns and prefabricated post and core. You say that the enrollee does 
not want extractions. The Plan denied your request. The Plan says there is less than 50% bone support on tooth 
#'s 8 & 9. The Plan also says that there is a clinically unacceptable root canal fill.  
 
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 crowns 
and prefabricated post and core 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 crowns and prefabricated post and 
core. Our reviewer says that the services are not medically necessary. Our physician reviewer found due to the 
lack of adequate bone support of tooth #'s 8 and 9, and the clinically unacceptable root canal fillings, the 
criteria for coverage for a post and core (D2954) for tooth #8 and crowns (D2750) for tooth #'s 8 and 9 have 
not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns and prefabricated post and core have not been met. Therefore, we 
decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 8 & 9 and a prefabricated post 
and core in addition to crown (D2954) for tooth #8.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve osseous surgeries (D4260) of the upper left, lower left, upper right, 
and lower right quadrants. 
 
You asked the Plan to pre-approve the osseous surgeries. You say that you would like authorization for the 
osseous surgeries. The Plan denied your request. The Plan says that the criteria for coverage was not met. The 
Plan also says that there has been no history of scaling and root planing or updated charting that has been 
completed. 
 
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 osseous 
surgeries 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 osseous surgeries. Our reviewer 
says that the service meets coverage criteria. Our physician reviewer found the x-rays show significant bone 
loss and pathological periodontal pockets. 
 
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 osseous surgeries have been met. Therefore, we decided that the Plan has to 
pre-approve osseous surgeries (D4260) of the upper left, lower left, upper right, and lower right quadrants.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Alpha Rollator/upright walker 
 
You asked the Plan to pre-approve an Alpha Rollator/upright walker. You say that a regular walker causes you 
discomfort and arm pain. The Plan denied your request. The Plan says the submitted documentation does not 
support the request. 
 
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 Alpha Rollator/upright walker. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does reveal a mobility limitation but the documentation does not 
reveal that the enrollee is unable to complete MRADLs in the home. The documentation reveals that the 
enrollee already has a cane and a walker and there is no documentation from the therapist or the physician that 
the enrollee is unsafe or unable to complete MRADLs with the current assistive devices. The documentation 
does not support that the enrollee can use the Alpha Rollator/Uprite Walker safely or that the enrollee requires 
this device over a standard walker. 
 
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 Alpha Rollator/upright walker have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an Alpha Rollator/upright walker
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the 
upper right, lower right, upper left, and lower left quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says the 
service does not meet criteria. 
 
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 scalings 
and planings (D4341) 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 scalings and planings (D4341). Our 
reviewer says that the service does not meet coverage criteria. Our physician reviewer found the upper right 
quadrant has only one tooth present, and therefore would not qualify under the code D4341, which required 
there are four or more involved teeth in a quadrant. Our reviewer found that the upper left quadrant has three 
teeth present and also would not qualify under that code.  Our reviewer also found that the lower right and 
lower left quadrants have sufficient numbers of teeth present, but does not have four or more involved teeth in 
any quadrant that shows bone loss of significance such that the roots would be accessible to scaling and root 
planing. 
 
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 scalings and planings (D4341) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the upper right, 
lower right, upper left, and lower left quadrants.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE).
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. Medicare rules say that TTE 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 submitted records show that the enrollee has leg edema but no documented cardiac symptoms. There are no documented cardiac physical exam abnormalities, including jugular venous distension or inability to assess jugular venous pressure. In this circumstance of no documented cardiac symptoms or jugular venous pressure, the TTE does not meet the criteria for coverage 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 a transthoracic echocardiogram (TTE).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacro-iliac (SI) 
joint nerves. 
 
You asked the Plan to pre-approve the RFA procedure. You say that this would be helpful. The Plan denied 
your request. The Plan says this is not a proven treatment. 
 
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 RFA procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is an 83-year-old woman with chronic low back pain. She rates the pain as 8/10. 
Treatment has included medical therapy with opiates, muscle relaxants, steroids, NSAIDs, anxiolytics, and 
anti-depressants.  According to the documentation she had success with a block of the left sacral lateral 
peripheral branches of S1, S2, and S3.  The provider has requested sacral radiofrequency ablation of S1, S2, 
S3, S4. This treatment is considered experimental/investigational for this condition. 
 
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 RFA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the sacro-iliac (SI) joint nerves.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the claim should be 
processed to provide continuity of care. The Plan denied your request. The Plan says a home exercise regimen 
would be adequate. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 10 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive 
therapy and was trained in a home exercise program. Our reviewer says that the unique skills of a professional 
therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve canaloplasty.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of cataracts and glaucoma and has been treated with topical medications. She has a demonstrated visual acuity of 20/30 and 20/25, intraocular pressure of 13 bilaterally, and right central visual field scotoma. She has well-controlled open angle glaucoma. The requested canaloplasty is not the standard of care for the enrollee's condition, as it is not more beneficial than current available treatments. The services are therefore 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 canaloplasty.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scalings and root planings (D4341) of the upper right, 
lower right, upper left, and lower left quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says that 
the service is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the scalings 
and planings 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 scalings and planings. Our reviewer 
says that the service is medically necessary. Our physician reviewer found due to the presence of pathological 
periodontal pockets, bone loss and calculus formation the criteria for coverage for periodontal scaling and root 
planing (D4341) have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scalings and planings have been met. Therefore, we decided that the Plan 
has to pre-approve periodontal scalings and root planings (D4341) of the upper right, lower right, upper left, 
and lower left quadrants.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750) for tooth #'s 3, 5, & 7 and 
pontics (D6240) for tooth #'s 4 & 6. 
 
You asked the Plan to pre-approve the retainer crowns and pontics. You say that you cannot smile without your 
upper front tooth. The Plan denied your request. The Plan says the services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers 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 services do not meet the Plan's coverage criteria. Our physician reviewer found as there 
are other missing teeth in the arch, and no clear defect with the existing bridge #3 to 5 that would require 
replacement, the Plan criteria for fixed prosthetics would not be met. Our reviewer also found that a removable 
appliance may be considered to replace tooth #7 as well as other missing teeth. 
 
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 3, 5, & 7 and pontics (D6240) for 
tooth #'s 4 & 6.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF care.
You asked the Plan to pre-approve the continued SNF care. You say that you need more therapy to get your strength back and be able to take care of yourself. You also say that you need to continue getting physical help. The Plan denied your request. The Plan says as of June 1, 2020, you no longer qualified for care at the SNF level.
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 continued SNF care. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF care.