Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion surgery (27279, 22850). 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that this is medically necessary and you are 
allergic to helpful medication. The Plan denied your request. The Plan says you have not had a positive 
response to a cluster of 3 provocative tests. 
 
The Plan follows Medicare rules. Medicare rules say that that minimally-invasive surgical (MIS) fusion of the 
sacroiliac (SI) joint is considered medically necessary when all of the LCD 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 spinal fusion surgery. Our reviewer 
says that the criteria for coverage of the requested procedures have not been met. Our physician reviewer found 
although the plan issued a denial based upon a lack of provocative testing, the documentation indicates that this 
has been performed. However, the provided documentation is insufficient to satisfy the remaining elements of 
the local coverage determination. For example, the record does not indicate imaging to rule out hip pathology 
was performed or that there was a 75% percent reduction in pain and the ability to perform previously painful 
maneuvers following a sacroiliac joint injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion surgery (27279, 22850).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental and investigational. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One injection (J7326).
You asked the Plan to pre-approve Gel-One injection. You say that Gel-One injection is medically necessary. The Plan denied your request. The Plan says that the requested injection is not medically necessary. The Plan says that the enrollee has not tried and failed at least 3 months of conservative, nonpharmacological therapy and simple analgesics. The Plan also says that the enrollee has not failed to respond to aspiration and intra-articular injection of a steroid agent into the affected knee.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gel-One injection. Our reviewer says that the Gel-One injection is not medically necessary. Our physician reviewer found the provided documentation does not indicated a failure of at least 3 months of conservative treatment such as a home exercise program, education, weight loss, physical therapy or simple analgesics and non-steroidal anti-inflammatory 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 Gel-One injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One injection (J7326).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve muscle testing (5885, 95886) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON muscle testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is available from in-network providers.
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 muscle testing (5885, 95886) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120) and a reline of 
a complete maxillary denture (D5750). 
 
You asked the Plan to pre-approve the complete mandibular denture and reline of a complete maxillary 
denture. You say that you need these services to be approved for coverage. The Plan denied your request. The 
Plan says these services are not covered under your 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. Therefore, we decided that the Plan does not have to pre-approve a 
complete mandibular denture (D5120) and a reline of a complete maxillary denture (D5750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP device and supplies provided from May 11, 2020, through December 11, 2020.
You asked the Plan to waive the coinsurance for the CPAP device and supplies. You say that you didn't really use the CPAP, so you returned it. You say that you are not able to afford the coinsurance. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered items. You have been asked to pay a total of $202.45 for the CPAP device and supplies.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
May 11, 2020
CPAP Device
$33.68
20%
$6.74
May 11, 2020
CPAP Supplies
$277.04
20%
$55.41
June 11, 2020
CPAP Device
$64.79
20%
$12.96
July 9, 2020
CPAP Supplies
$47.84
20%
$9.57
July 11, 2020
CPAP Device
$64.79
20%
$12.96
August 10, 2020
CPAP Supplies
$294.35
20%
$58.87
August 11, 2020
CPAP Device
$64.79
20%
$12.96
October 11, 2020
CPAP Device
$64.79
20%
$12.96
November 11, 2020
CPAP Device
$64.79
20%
$12.96
December 11, 2020
CPAP Device
$35.28
20%
$7.06
TOTAL:
$202.45
CPAP device and supplies fall within the "Durable medical equipment (DME) and related supplies" benefit category. The records show that you are only responsible for the 20% coinsurance. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the CPAP device and supplies provided from May 11, 2020, through December 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary rehab to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve pulmonary rehab. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services can be provided by a network 
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 
pulmonary rehab to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic surgery services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services 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 
orthopedic surgery services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM 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 therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not test four or 
more times a day, or inject insulin 3 or more times daily. Based on this information, we decided that Medicare 
rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says a IRF admission is 
not medically necessary. The services this member requires can be rendered in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical treatment of a hip fracture after a fall. The enrollee's medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a mastectomy bra with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is a network provider available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for a mastectomy bra with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that you don't understand why this request was denied. 
The Plan denied your request. The Plan says this is 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 the monitor. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have not been using insulin multiple times per day. Your treatment does not require 
frequent adjustment on the basis of testing results. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) and mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that 
you need these services to be approved. The Plan denied your request. The Plan says these services are not 
covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture (D5225) and mandibular partial denture (D5226).
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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different 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 in the Medicare rules section. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the 
medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF level of 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neck-spine fusion (22600), spinal fusion (22614), and 
insertion of a spine fixation device (22842). 
 
You asked the Plan to pre-approve a neck-spine fusion, spinal fusion, and insertion of a spine fixation device. 
You say that the requested services are medically necessary for the enrollee. The Plan denied your request. The 
Plan says rules for pre-approval have not been met because the record does not contain sufficient 
documentation of medical necessity. 
 
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 neck-spine fusion, spinal fusion, and 
insertion of a spine fixation device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the medical records indicate 
that the enrollee is a smoker and is still smoking. Smoking is a contraindication to pseudoarthrosis revision 
fusion surgery. Criteria for coverage are not met. 
 
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 neck-spine fusion, spinal fusion, and insertion of a spine fixation device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a neck-spine fusion (22600), 
spinal fusion (22614), and insertion of a spine fixation device (22842).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head. 
 
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 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 not medically necessary. Our physician reviewer found the enrollee has left-sided hearing loss 
and pulsatile tinnitus. He was also diagnosed with a possible cholesteatoma of the left ear based on magnetic 
resonance imaging (MRI) findings. A CT of the head/temporal bones was performed November 18, 2020 but 
the report was not provided. There is insufficient justification for a repeat CT, as repeat MRI is sufficient and 
appropriate to further define the lesion. The services are 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 computed tomography (CT) scan of the head.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve innerspring mattress (E0271). 
 
You asked the Plan to pre-approve the mattress. You say that your doctor says that you need a replacement 
mattress. You have been having more back problems and wake up stiff from your mattress. You have went 
through pain blockers and they will not do surgery on your back. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. This item is only covered for a beneficiary owned hospital bed. The 
records show you have a king size recliner bed not a hospital bed. Based on this information, we decided that 
Medicare rules for coverage of the mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve innerspring mattress (E0271).