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

We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #19 and retainer crowns 
(D6740) for tooth #'s 18 and 20. 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that the Plan advised that you 
would be covered for a bridge at 75% of cost, and you would be responsible for the remaining 25%. You also 
say that your plan covers $3,000 worth of dental coverage for the 2020 plan year. The Plan denied your 
request. The Plan says the documentation fails to indicate or support any specific physical or psychological 
condition(s) that preclude the use of a removable prosthesis. 
 
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 pontic and 
retainer crowns 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 pontic and retainer crowns. Our 
reviewer says that there is no necessity for the requested procedures. Our physician reviewer found tooth #18 
had endodontic treatment, and the mesial edge of the tooth appears to have prior decay that extended to the 
level of the bone. In cases where there is insufficient tooth structure remaining for restorative treatment, the 
tooth would either be deemed non-restorable or if possible, a surgical procedure to expose more solid tooth 
structure would be required. Our reviewer found that given the presentation of tooth #18, it would not be 
considered a viable abutment it its current form. In addition, the Plan's criteria for bridgework allows for such 
appliances only where there is a neurological or medical condition that would preclude the use of such 
appliance.  Our physician reviewer also found that there has been no supplied documentation of any medical or 
neurological issue that would make the use of a removable appliance unreasonable. 
 
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 pontic and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pontic (D6245) for tooth #19 and retainer crowns (D6740) for tooth #'s 
18 and 20.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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 was 
admitted for total knee replacement. Medical problems are stable. There are no identified problems that need 
inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. 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. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there are no acute 
medical problems, and no evidence of a need for multiple therapies. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for complications related to esophageal surgery. The 
complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a need for 
physical therapy, but does not support a need for, or the ability to tolerate an intensive rehabilitation therapy 
program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81201, 81203, 81242, 81292, 
81294, 81404, 81297, 81298, 81300, 81317, and 81319 provided on December 11, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81201, 81203, 81242, 81292, 81294, 81404, 81297, 81298, 81300, 81317, and 81319 
are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must 
reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the 
laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical 
documentation and/or claim history indicates that the specimen was obtained in an office setting place of 
service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
81201, 81203, 81242, 81292, 81294, 81404, 81297, 81298, 81300, 81317, and 81319 provided on December 
11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to provide 30 vision therapy visits. 
 
You asked the Plan to provide 18 additional vision therapy visits (97110, 97530, 92065). You say that the 
treatment is medically necessary. The Plan denied your request. The Plan says s they will approve 12 but the 
records do not show a medical need for the 18 remaining requested vision therapy visits 
 
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 provide 18 additional vision therapy visits (97110, 
97530, 92065). 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 vision therapy is one treatment 
modality used for convergence insufficiency. The use of prism within glasses can also help enrollee's who are 
symptomatic. Vision therapy is performed by optometrists.   
 
 
 
Some of the exercises can also be performed at home by the enrollee independent of the practitioner. Per 
optometrists notes, the goal of vision therapy is to resolve or normalize these symptoms. Vision therapy can be 
beneficial in the treatment of symptomatic convergence insufficiency but there is no standard of the duration of 
therapy. The amount of allotted visits (12) per insurance guidelines is reasonable under accepted standards of 
practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 18 additional vision therapy visits (97110, 97530, 92065) have not been met. 
Therefore, we decided that the Plan does not have to provide 18 additional vision therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelower extremity prostheses.You asked the Plan to pre-approveAll lower extremity prostheses, flex-walk system or equal (L5981) and All lower extremity prostheses, multi-axial rotation unit (L5986). You say that the requested prosthesis represents the least level of technology required to safely meet the enrollee's activities of daily living.The Plan denied your request. The Plan says the requested K3 components exceed the member's needs and cannot be covered.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked ourphysician 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 All lower extremity prostheses, flex-walk system or equal (L5981) and All lower extremityprostheses, multi-axial rotation unit (L5986). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no objective treating medical practitioner medical records or progress notes indicating that the enrollee is aK3 ambulator. The documentation indicates documentation from the vendor but without corroborating treating medical practitioner medical progress notes the request for the All lower extremity prostheses, flex-walk system or equal (L5981) and All lower extremity prostheses, multi-axial rotation unit (L5986) cannot be considered 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 All lower extremity prostheses, flex-walk system or equal (L5981) and All lower extremity prostheses, multi-axial rotation unit (L5986) have not been met.Therefore, we decided that the Plan does not have to pre-approvelower extremity prostheses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 3ml LL syringe MIS 22GX1. 
 
You asked the Plan to pre-approve the syringe. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is self-injectable. 
 
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 a 3ml LL syringe MIS 
22GX1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on arthrotomy (27052) and 
incision and drainage (26991) provided by a RNFA on May 18, 2020. 
 
You asked the Plan to pay for surgical assistant services. You say that these are payable codes. The Plan denied 
your request. The Plan says surgical assistant services are not covered from this provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on 
arthrotomy (27052) and incision and drainage (26991) provided by a RNFA on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot and ankle feature for a prosthetic leg. 
 
You asked the Plan to pre-approve All lower extremity prostheses, foot, flexible keel (L5972) and All lower 
extremity prostheses, multi-axial rotation unit (L5986). You say that a well fitted well aligned prosthesis will 
improve strength and stability, stamina and balance, and safety. The Plan denied your request. The Plan says 
the record does not show the member is ambulatory. 
 
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 All lower extremity prostheses, foot, 
flexible keel (L5972) and All lower extremity prostheses, multi-axial rotation unit (L5986). Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the criteria for Social Security Act, Section 1862(a)1(A) and Local Coverage Determination 
(LCD): Lower Limb Prostheses (L33787) for an All lower extremity prostheses, foot, flexible keel (L5972) 
have not been yet. The documentation does not reveal objective physician or treating medical practitioner 
progress notes that indicate that this enrollee is or has the potential to be ambulatory at a K2 level. The 
submitted medical records do not support that this enrollee is ambulatory or has the potential for ambulation. 
Supplier produced records are not considered part of the medical record. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of All lower extremity prostheses, foot, flexible keel (L5972) and All lower 
extremity prostheses, multi-axial rotation unit (L5986) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an advanced foot and ankle feature for a prosthetic leg.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an arterial embolization procedure. 
 
You asked the Plan to pre-approve an arterial embolization procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says medical necessity has been established. 
 
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 arterial 
embolization procedure. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer could not find any guidelines to support the requested 
treatment for enrollees with subdural hematoma. Medical necessity has not been established. We looked at this 
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of arterial embolization procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an arterial embolization procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 7, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the hospital and was found to be gravely ill and was 
admitted to the intensive care unit for further diagnostic and supportive cares. The enrollee was soon found to 
have a life-threatening bleed and he was quickly discharged into hospice care on June 7, 2020. The 
documentation did not show that at the time of inpatient admission the admitting physician reasonably expected 
that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on June 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you would like reconsideration because the orthotics are necessary to stabilize your ankles and prevent falls.The Plan denied your request. The Plan says based on Medicare criteria, the orthotics are not reasonable and necessary.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot diseaseor for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the services. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services received are neither emergent nor urgent 
and prior authorization was not obtained to seek out-of-network care. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on March 9, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete upper denture (D5110), a complete lower denture (D5120), and a cone beam CT image capture with field of view of both jaws (D0383).You asked the Plan to pre-approvethe dental services. You say that your dentures were stolen. You say that you have no teeth. You say that you are not able to eat. You also say that you need the dentures for every day life.The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan says that the frequency limit has been reached. The Plan also says that cone beam CT is not listed as a covered service.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 frequency limit of once every 5 plan years for dentures has been reached. The record shows that you received a complete set of dentures on January 3, 2019, thus the frequency limit has been reached. Additionally, cone beam CT is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea complete upper denture (D5110), a complete lower denture (D5120), and a cone beam CT image capture with field of view of both jaws (D0383).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have appointments 
that you need transportation for. The Plan denied your request. The Plan says your request exceeds the Plan's 
coverage. 
 
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 a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that with the trips the Plan has approved, you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for preventative vaccines provided on July 13, 2020. 
 
You asked the Plan to pay for preventative vaccines under Medicare Part B. You say that preventative vaccines 
should be covered by the Plan. The Plan denied your request. The Plan says the vaccines provided are not 
covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventative 
vaccines under Medicare Part B. The Plan follows the same rules. The records do not show that you have been 
injured or directly exposed to any illness related to preventative vaccines under Medicare Part B. Therefore, we 
decided that the Plan does not have to pay for preventative vaccines provided on July 13, 2020.  
 
Benefits for preventative vaccines may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.