Persius/hicric huggingface dataset:
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 you do not feel safe leaving the hospital. The Plan 
denied your request. The Plan says that there is no indication that lower level of care such as a skilled nursing 
facility would not be able to provide the appropriate therapy services. 
 
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. 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 were admitted for myocardial infarction, coronary 
artery bypass grafting, and congestive heart failure. Your medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF 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: 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 IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility.  
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis (74177) and of the chest (71260). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis and of the chest. You say that the 
requested CT scans are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
medical necessity rules for the requested CT scans have 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 a CT scan of the abdomen and pelvis 
and of the chest. Our reviewer says that the requested CT scans are not medically reasonable and necessary in 
this case. Our physician reviewer found that the enrollee had a normal CT of the chest/abdomen/pelvis for 
metastatic disease in December 2021. There is no specific clinical rationale for the CT scans requested in this 
case. 
 
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 CT scan of the abdomen and pelvis and of the chest have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
abdomen and pelvis (74177) and of the chest (71260).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion (27279). 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that minimally-invasive surgical (MIS) fusion of the 
sacroiliac (SI) joint is considered medically necessary when all of the criteria listed in the rules section 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 sacroiliac joint fusion. Our reviewer 
says that the requirements for coverage of sacroiliac joint fusion have not been met. Our physician reviewer 
found the submitted records do not include detailed documentation regarding specific sacroiliac joint pain. The 
most recent exam did not provide any findings for the sacroiliac joints. Additionally, multiple other plausible 
pain generators are present. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint fusion (27279).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on September 16, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2 continuous glucose monitor sensors. 
 
You asked the Plan to pre-approve these services. You say that these are medically necessary. The Plan denied 
your request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. 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 FreeStyle Libre 2 
continuous glucose monitor sensors.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled care services. 
 
You asked the Plan to pre-approve home health. You say that you are not yet strong enough and have fallen 
recently. The Plan denied your request. The Plan says the denial of authorization for additional home health 
skilled care is correct. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health. Our reviewer says that 
you do not meet the Medicare criteria for home health skilled care. Our physician reviewer found the record 
does not support that you require additional skilled rehabilitation services that are medically necessary to 
provide treatment, care, improve your condition, or perform a maintenance program. You have been stable 
without and recent exacerbations of your condition or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health skilled care services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on November 19, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that all additional medical or surgical services required of 
the surgeon during the postoperative period of the surgery because of complications which do not require 
additional trips to the operating room are included in the global surgical package. 
 
We looked at the file and Medicare rules. The file shows that the enrollee received a surgical procedure on 
August 30, 2021. The services at issue were performed within the 90-day global surgical period and payment is 
included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the 
surgical services rendered on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subarachnoid injection (62320), provided on November 
15, 2021. 
 
You asked the Plan to pay for the subarachnoid injection. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this service is considered experimental. 
 
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 pay for the subarachnoid injection. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not contain sufficient information in the medical records submitted. In addition, the records submitted were not dated and not signed. 
 
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 subarachnoid injection have not been met. Therefore, we decided that the 
Plan does not have to pay for the subarachnoid injection (62320), provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for photochromatic lens tint (V2744), progressive lenses 
(V2781) and polycarbonate coating (V2784) provided on January 17, 2022. 
 
You asked the Plan to pay for the lens upgrades. You say that these services were necessary and should be 
covered. The Plan denied your request. The Plan says these services are not covered by your vision benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $200 for eyeglasses (lenses and frames) or up to $200 for contact lenses every 
two years. 
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, lens enhancements are not 
among the items/services covered under this benefit. In addition, the documentation shows that the billed cost 
of the eyeglasses was $545, not including the cost for the eye exam and refraction. The documentation 
indicates that you paid $236 for these services. Therefore, we decided that the Plan does not have to pay for 
photochromatic lens tint (V2744), progressive lenses (V2781) and polycarbonate coating (V2784) provided on 
January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum surgery on 4+ teeth in all quadrants. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information must show that there has been treatment done to remove the plaque and 
tartar from the teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the services 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the submitted 
information is unclear as to the gingival condition of the teeth, though insurance notes indicate there is 
continued inflammation of the gums even following prophylaxis. There is no periodontal pocketing 
information provided, and no clear indication of any hyperplasia of the gums. Gingivectomy is not considered a 
treatment for inflammation of the gingiva unless there are clear issues of increased tissue formation for reasons 
of drug effects or hormonal disturbances or some developmental anomaly. In this case there does not appear to 
be a clinical rationale for tissue removal given the symptoms of only gingival inflammation.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve gum surgery on 4+ teeth in all quadrants.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous Spacer for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that this would provide significant clinical and 
quality of life benefits for the enrollee. The Plan denied your request. The Plan says that this is considered 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion Interspinous Spacer for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the medical records provided support the need 
for SNF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The 
Plan says that the enrollee's needs can be met at a lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital.  The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis.  She is medically stable and can receive further rehab services at a lower level of care.  
Although further rehabilitation services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee 
does not have any parental medication; complex wound care or nutrition given via a feeding tube.  She is 
medically stable without any acute exacerbations of chronic medical problems.  Her physical function is at or 
near her baseline and she can receive services at a lower level of care.  Admission to a SNF for inpatient skilled 
rehab services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid repair/modification (V5014) and hearing aid 
supplies/accessories (V5267) provided on November 12, 2021. 
 
You asked the Plan to pay for hearing aid services. You say that these services were necessary. The Plan denied 
your request. The Plan says these services are not covered by your hearing benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
Though the Plan offers a supplemental hearing benefit in excess of Medicare coverage, the requested services 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for hearing aid repair/modification (V5014) and hearing aid supplies/accessories (V5267) provided on November 
12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) provided by a 
participating provider on January 4, 2022. 
 
You asked the Plan to pay for panoramic radiographic imaging. You say that you should not have to pay for 
this mistake. The Plan denied your request. The Plan says this claim has been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers panoramic 
radiographic imaging once every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0330 was previously provided 
on March 2, 2021. Based on this information, we decided that the Plan's rules for coverage of panoramic radiographic imaging have not been met. Therefore, we decided that the Plan does not have to pay for 
panoramic radiographic imaging (D0330) provided by a participating provider on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
by a participating provider on September 20, 2021. 
 
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you would greatly 
appreciate the Plan paying for these services. The Plan denied your request. The Plan says the rendered dental 
service is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pay for a 
comprehensive periodontal evaluation (D0180) provided by a participating provider on September 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that the isolated recurrence is due to local failure of the 
enrollee's initial chemoradiation rather than immune therapy. You say that the immune therapy can still be 
useful to prevent distant failure. The Plan denied your request. The Plan says the requested drug is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Imfinzi. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has recurrence and is 
therefore no longer a candidate for Imfinzi, as it is not a controlling disease. Our physician reviewer found that 
Imfinzi is FDA approved, not for continuation with progression. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi.