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

 
We decided that the Plan does not have to pre-approve the unlisted procedure, dentoalveolar structures (CPT 
Code 41899). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary for the patient 
to have this as they are in need of a cardiac procedure that that are currently unable to have until their dental 
issue has been addressed. The Plan denied your request. The Plan says this service is not covered under 
Medicare or the Health Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking 
the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the 
structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by 
Medicare. The periodontal scaling and root planning (billed as 41899, unlisted procedure, dentoalveolar 
structures) that you are requesting does not meet the requirements for approval. Your record indicates you are 
requesting this service prior to heart surgery. Items and services in connection with the care, treatment, filling, 
removal, or replacement of teeth, or structures directly supporting the teeth are not covered. Structures directly 
supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal 
membrane, cementum, and alveolar process. Therefore, we decided that the Plan does not have to pre-approve 
the unlisted procedure, dentoalveolar structures (CPT Code 41899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214), extraction 
(D7140), addition of tooth to an existing partial denture (D5650), and periodontal scalings and root planings 
(D4341) of four or more teeth per quadrant of the UL, LR, and LL quadrants. 
 
You asked the Plan to pre-approve the mandibular partial denture, extraction, addition of tooth to an existing 
partial denture, and scalings and planings. You say that it is recommended that the enrollee receive these 
services. The Plan denied your request. The Plan says mandibular partial denture (D5214), extraction (D7140), 
addition of tooth to an existing partial denture are not covered benefits under the Plan. The Plan also says that 
the x-ray demonstrates the presence of only 2 teeth in the UL and LL quadrants, and only 3 teeth in the LR 
quadrant. 
 
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 
mandibular partial denture, extraction, addition of tooth to an existing partial denture, and 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 request for periodontal treatment does not meet Plan criteria. Our physician reviewer found the 
provided radiographs reveal there are only two teeth in the UL and LL quadrants, and three teeth in the LR 
quadrant. There is obvious bone loss on all teeth in the mouth, however, there is no periodontal charting 
included to review.  Our reviewer found that the UL and LL quadrants have less than four teeth in each 
quadrant, as does the LR quadrant.  Our physician reviewer also found that these quadrants do not meet the 
requirement of there being four or more teeth in a quadrant under code D4341. 
 
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 mandibular partial denture, extraction, addition of tooth to an existing 
partial denture, and scalings and planings have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a mandibular partial denture (D5214), extraction (D7140), addition of tooth to an existing 
partial denture (D5650), and periodontal scalings and root planings (D4341) of four or more teeth per quadrant 
of the UL, LR, and LL quadrants.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the admission to inpatient level of hospital care. 
 
You asked the Plan to pre-approve the admission to inpatient level of hospital care. You say that it is 
recommended that the enrollee have a laparoscopic revision of gastrojejunostomy and diagnostic laparoscopy. 
Please review the clinical documentation and provide an authorization decision. The Plan denied your request. 
The Plan says that the procedure can be started at observation level of care and then if a complication happens 
the facility can then submit a request to transition the level of care from observation to inpatient with 
supporting documentation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollee's 
condition can be managed safely only in the inpatient hospital setting.  
 
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 inpatient level of hospital care. Our 
reviewer says the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has a gastrojejunal stricture after gastric bypass procedure which has 
failed conservative and endoscopic treatment. The enrollee is unable to eat and is provided nutritional support 
via a feeding tube. The standard treatment is either open or laparoscopic revision of the gastrojejunal 
anastomosis to relieve the stricture, narrowing. The procedure is not amenable to outpatient or observation 
level of care. At least one acute inpatient day would be considered for this type of laparotomy, complexity and 
risk of complications such as leak/bleeding. 
 
 
 
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 inpatient level of hospital care have been met. Therefore, we decided that 
the Plan has to pre-approve the admission to inpatient level of hospital care.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Boost, nutritional supplement (B4150). 
 
You asked the Plan to pre-approve the Boost, nutritional supplement. You say that please review the request for 
B4150 Enteral Formula and provide determination. The Plan denied your request. The Plan says nutritional 
supplementation is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve the Boost, nutritional supplement (B4150).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS implanted device (33289, 93264). 
 
You asked the Plan to pre-approve a CardioMEMS implanted device. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 CardioMEMS implanted device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to 
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare 
coverage criteria are not met since the device should still be considered experimental or investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS implanted device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a CardioMEMS implanted device (33289, 93264).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 robotic assisted rehabilitation device. 
 
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 had right brain tumor 
resection for metastatic melanoma in October of 2017, resulting in left upper extremity weakness. She is 
limited in left upper extremity function and the physician states she has failed traditional therapies to improve 
left arm function and requires the MyoPro 2 robotic device to gain independence and function. There is 
insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes or patient 
management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis from 
conditions such as the patient's hemiparesis from her brain tumor resection,or other  
neuromuscular/neurological disease or injury. The services are not reasonable and necessary for the diagnosis 
or treatment of illness or injury or to improve the functioning of a malformed body member. 
 
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 MyoPro 2 robotic assisted rehabilitation device.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a selective nerve block. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a selective nerve block 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 medically necessary. Our physician reviewer found the enrollee has a history of low back pain 
due to lumbar stenosis with neurogenic claudication and lumbar radiculopathy. She had minimally invasive 
surgery, lumbar laminectomy, and foraminotomies on July 8, 2019. The requested L5-S1 selective nerve block 
meets the criteria for coverage and 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 pre-
approve a selective nerve block.  
 
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 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 pneumonia. Medical problems are stable. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hearing aids to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the hearing aids. You say that the hearing aids are less expensive through 
the out-of-network provider. The Plan denied your request. The Plan says hearing aids must be obtained from a 
contracted provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the hearing aids to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Lumbar Spine 
(72131). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found there was no specific clinical rationale for 
the requested CT scan. There was no documentation of any physical exam abnormalities. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Computed Tomography (CT) of the Lumbar Spine (72131).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto 24mg-26mg tablets. 
 
You asked the Plan to pre-approve Entresto. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says this drug is not covered under the Part B medical benefit. 
 
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 Entresto 24mg-26mg 
tablets.  
 
Benefits for Entresto 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (E2361, E1028, 
E2377, E2313, E1007, E2620, E2311, E0955, K0108, E1012, E2605) for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that the current wheelchair is in poor condition, 
does not meet the enrollee's needs, and exceeds the manufacturer's recommended lifespan. The enrollee is 
independent in toileting, self-feeding, grooming therefore there is no evidence the enrollee needs an expandable 
controller/harness/electrical connection rather than controlling any power option with their own switches. The 
documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-
proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices 
(e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators 
through the drive control, a  separate display (i.e., for alternate control devices),other electronic devices (e.g., 
control of an augmentative speech device or computer through the chair's drive control), or an attendant 
control. As the requested wheelchair and accessories are not medically necessary the request for a sealed 
battery and positioning cushion are not medically necessary. The Plan denied your request. The Plan says this 
is not medically necessary. 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair and accessories are not medically reasonable or necessary. Our physician reviewer 
found the documentation does not reveal a detailed and objective in-person assessment of the upper extremities 
evaluating why the enrollee is unable to be helped by a manual wheelchair. There is no evidence that a power 
seating system is needed for pressure ulcers, to manage spasticity, or for intermittent catheterization. The 
enrollee 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair and accessories (E2361, E1028, E2377, E2313, E1007, E2620, E2311, 
E0955, K0108, E1012, E2605) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physician's services with the requested provider. 
 
You asked the Plan to pre-approve the physician's services. You say that the enrollee has made multiple 
attempts to find an in-network specialist and he has not been able to get the care he needs. You say the enrollee 
is in a lot of pain and needs to be seen by someone. The Plan denied your request. The Plan says the requested 
physician is not contracted with the member's closed panel provider system.  There is a contracted provider in 
the member's MMCE closed network that specializes in treatment of TMJ who is accepting new members with 
PCP referral. 
 
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 contract with 
the Plan also says that the enrollee is required to receive covered services from the network providers in the 
enrollee's selected Provider System. 
 
The requested provider in this case is not a network provider with the Plan. The requested provider in this case 
is not contracted with the enrollee's closed panel provider system. The Plan has network providers available 
who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-
approve these services. Therefore, we decided that the Plan does not have to pre-approve the physician's 
services with the requested provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractor services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractor services. You say that you have established care with this 
provider. You say that you do not like the in-network provider. The Plan denied your request. The Plan says 
there are in-network providers available for these services. 
 
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 
chiropractor services to be provided by an out of network (OON) provider.