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

We decided that the Plan has to pre-approve the bilateral dilation of eustachian tubes.

You asked the Plan to pre-approve the requested services. You say that the service will allow your hearing to be restored. The Plan denied your request. The Plan says that this service is considered experimental.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that you were evaluated for worsening bilateral otalgia, aural fullness/pressure, and subjective hearing loss. You also had bilateral sinonasal symptoms including facial pain/pressure, nasal congestion, and postnasal drainage. Prior treatments included nasal steroid spray, oral antihistamines, saline sinus rinses, and multiple courses of oral antibiotics with no improvement in sinonasal symptoms. You also had a history of tympanostomy tube placement and bone-anchored hearing aid implant. Physical examination of the head and neck, including endoscopy, was unremarkable. An audiogram demonstrated right-sided conductive hearing loss. Based on available clinical documentation, the requested services meet criteria for being medically necessary and reasonable. Your symptoms are consistent with obstructive eustachian tube dysfunction (ETD) as described by the American Academy of Otolaryngology-Head and Neck Surgery Foundation 2019 clinical consensus statement on balloon dilation of the Eustachian tube. You underwent endoscopy, and no extrinsic causes of eustachian tube dysfunction were documented. A balloon device to treat Eustachian tube dysfunction was approved by the Food and Drug Administration in 2016. Recent systematic reviews by Froehlich et al. (2018) and Huisman et al. (2020) reported that ETD complications were generally few, mild, and self-limited and that ETD was associated with improvement in subjective and objective outcomes for patients with eustachian tube dysfunction. In summary, the requested ETD services meet criteria for being medically necessary and reasonable to treat your eustachian tube dysfunction. 

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 requested services have been met. Therefore, we decided that the Plan has to pre-approve the bilateral dilation of eustachian tubes.

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 the peristeen anal irrigation system (A4459). 
 
You asked the Plan to pre-approve the peristeen anal irrigation system. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the requested items are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Enema systems (gravity and manual pump), 
codes A4458 and A4459 respectively, will be denied as statutorily non-covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the peristeen anal irrigation system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the peristeen anal irrigation system (A4459).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immune globulin injection, supplies for maintenance of 
non-insulin drug infusion catheter and infusion supplies for external drug infusion pump provided on May 15, 
2021. 
 
You asked the Plan to pay for the immune globulin injection, supplies for maintenance of non-insulin drug 
infusion catheter and infusion supplies for external drug infusion pump. You say that the medical records 
should be reviewed, and the claim processed for payment. The Plan denied your request. The Plan says the 
documentation submitted did not include an itemized shipping/billing invoice from the billing provider to 
indicate the specific supplies for the billed date of service.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid shipping/billing invoice to verify the billed supplies. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for the immune globulin injection, supplies for maintenance of non-insulin 
drug infusion catheter and infusion supplies for external drug infusion pump provided on May 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the intensity-modulated radiation therapy (IMRT).

You asked the Plan to pre-approve the IMRT. You say that the service is medically necessary. The Plan denied your request. The Plan says that the service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the IMRT. Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found IMRT is not experimental, but rather a useful tool available to radiation oncologists to potentially reduce toxicity and improve the dose distribution in patients when the dose-volume exposure of normal tissues warrant its use. ASTRO's position is that IMRT is necessary when the need is sufficiently supported. Justification for IMRT is provided in this case. As such, the need for IMRT is established and plausible and would be furnished in accordance with accepted standards of medical 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 the IMRT have been met. Therefore, we decided that the Plan has to pre-approve the intensity-modulated radiation therapy (IMRT).

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 the crown for tooth #3.

You asked the Plan to pre-approve the crown. You say that tooth #3 has gingival receding. You say that the tooth is very sensitive and needs coverage. The Plan denied your request. The Plan says the tooth does not meet required clinical criteria to establish medical necessity.

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 crown 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 crown. Our physician reviewer found that that there is an existing two surface restoration, but the majority of the tooth has its structure intact. Our reviewer says that given the requirements for crown coverage as well as the existing periodontal concerns, there is no medical necessity for the requested crown on tooth #3. 

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 crown have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown for tooth #3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine pontics (D6241 x9) and two retainer crowns 
(D6751 x2). 
 
You asked the Plan to pre-approve the pontics and retainer crowns. 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 nine 
pontics (D6241 x9) and two retainer crowns (D6751 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and mandibular 
partial denture (D5214) provided by a participating provider. 
 
You asked the Plan to pre-approve a maxillary partial denture and mandibular partial denture. You say that 
these dentures are medically necessary. The Plan denied your request. The Plan says there are other treatments 
which may be medically appropriate or 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 a maxillary 
partial denture and mandibular partial denture 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 a maxillary partial denture and 
mandibular partial denture. Our reviewer says that a maxillary partial denture and mandibular partial denture 
have not been met due to the condition of the remaining teeth. Our physician reviewer found once these other 
issues are treated, an evaluation of the prognosis for the partial dentures can be made. 
 
  
 
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 a maxillary partial denture and mandibular partial denture have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and 
mandibular partial denture (D5214) provided by a participating provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical and occupational therapy services to be
rendered by an OON provider.

You asked the Plan to pre-approve the physical and occupational therapy services. You say that the enrollee
resides in custodial care in an Assisted Living Community, and the requested treating provider has a contract
with the Assisted Living Community to provide outpatient therapy services on-site where the enrollee resides.
The Plan denied your request. The Plan says the enrollee has no OON benefits, and similar services are
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
physical and occupational therapy services to be rendered by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mobile cardiovascular telemetry (93229, 93228). 
 
You asked the Plan to pre-approve mobile cardiovascular telemetry. You say that you this following an 
emergency department visit. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that real-time outpatient cardiac telemetry is considered 
medically unnecessary if it is unlikely to provide clinical data or information beyond that which has already been obtained from a previous test or if other testing (e.g., electrocardiogram, 24 hour Holter, etc.) could be 
expected to provide the data/information needed for the diagnosis and/or treatment of the patient's 
condition/symptoms. 
 
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 mobile cardiovascular telemetry. Our 
reviewer says that the requested mobile cardiovascular telemetry is not medically necessary in this case. Our 
physician reviewer found the recent ambulatory electrocardiogram monitor has diagnosed your arrhythmia, 
resulting in treatment prescribed by your cardiologist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of mobile cardiovascular telemetry have not been met. Therefore, we decided that 
the Plan does not have to pre-approve mobile cardiovascular telemetry (93229, 93228).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for cataract surgeries you had at an 
ambulatory surgery center on April 28, 2021, and May 12, 2021. 
 
You asked the Plan to reduce the copayments for the cataract surgeries. You say that you did not see anything 
in your information that said there was a $250 cost for outpatient surgery.  You said that the Plan needs to 
improve its communication about charges. The Plan denied your request. The Plan says you were charged these 
copayments correctly.  The Plan says that because the allowed amount for each procedure ($244.77) is less than 
your copayment obligation, you are responsible for the full allowed amount for each. 
 
 
 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 a $275 
copayment for outpatient surgery in an ambulatory surgical center.  
 
You have been asked to pay a $275 copayment for the cataract surgeries. The cataract surgeries fall within the 
outpatient surgery in an ambulatory surgical center benefit category. 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 reduce the 
copayments for cataract surgeries you had at an ambulatory surgery center on April 28, 2021, and May 12, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the member has not yet 
stabilized in care and is in need of continued inpatient support. The Plan denied your request. The Plan says 
that the enrollee does not require 24 hour supervision. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee. It is not expected this enrollee would improve in a reasonable period of time as she does not have 
suicidal or homicidal ideation noted and no auditory or visual hallucinations. This patient does not show any 
abnormal behaviors or any symptoms which would require acute treatment. It does not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care as you do not have dangerousness to self or others but was compliant with her treatment. 
Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric 
hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a routine EEG. 
 
You asked the Plan to pre-approve a routine EEG. You say that you are losing your memory, you forget where 
you live, you can't answer questions from your doctor like you used to, and you are forgetting information that 
you need every day. The Plan denied your request. The Plan says the EEG 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 a routine EEG. Our reviewer says that 
the EEG is not considered medically reasonable and necessary. Our physician reviewer found the limited 
clinical information provided for review indicates that you have complaints of memory problems. There were 
no other neurological complaints noted. There was no significant neurological history noted. You have nothing 
to suggest the presence of a seizure disorder or a similar condition for which EEG is generally and customarily 
performed. EEG is otherwise not done /performed in the evaluation of memory complaints or problems. The 
testing modality is not specific and is otherwise non-diagnostic. Such testing in this case would not be 
appropriate for the clinical presentation. For these reasons the requested EEG would not meet the Medicare 
definition of medical necessity. 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 routine EEG have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a routine EEG.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and related 
accessories. 
 You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed 4 
weeks of conservative therapy. The Plan denied your request. The Plan says coverage criteria have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications. 
 
The file shows that a segmental pneumatic compressor and segmental pneumatic appliances were requested. 
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 requested services. Our physician 
reviewer found that there is no objective documentation in the submitted clinical notes to support the requested 
device. The enrollee's physical exam reveals no skin discoloration or lymphedema. The records do not show 
that the enrollee meets the requirements for coverage of the requested device. Therefore, the requested device 
and related accessories are not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pneumatic compression device and related accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the removal of torus mandibularis (D7473) provided on 
July 2, 2021. 
 
You asked the Plan to pay more for the removal of torus mandibularis. You say that while you were in the 
office, the provider contacted the Plan, and you were assured that this service was medical rather than dental. 
You also say that you believe this claim should be reconsidered as the service could not have been performed 
by your dentist and required the services of an oral surgeon. The Plan denied your request. The Plan says your 
annual $2,000 combined allowance for the 2021 Plan year was exhausted during this visit. The Plan also says 
that there are no call records on file from you or the provider. 
 
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 Plan offers a $2,000 combined 
allowance for supplemental preventive and comprehensive dental services every year. The contract says that 
you are responsible for any amount over and above the allowance amount. The record shows that you met the 
annual maximum benefit while processing this claim for the July 2, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the 
removal of torus mandibularis (D7473) provided on July 2, 2021.