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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 coronary artery bypass grafting.
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, in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (64633).
You asked the Plan to pre-approve facet joint radiofrequency ablation. You say that the enrollee has had a medial branch block. The Plan denied your request. The Plan says the records do not show that the enrollee has had two successful medial branch blocks.
The Plan must follow Medicare rules. Medicare rules say that an initial thermal radiofrequency ablation (RFA) of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic Medial Branch Blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of primary (index) pain. We looked at the file and Medicare rules. While the submitted medical records show that the enrollee had 80% pain relief from a MBB, there is no documentation of a second MBB being performed as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (64633).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that a transfer to a LTACH facility is medically necessary. The Plan denied your request. The Plan says the enrollee's status is stable and improving. The Plan says that a transfer to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient appears to be improving and is more stable at this time. The enrollee requires only short-term additional acute care services that can be safely administered at the current facility until they can be transferred to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for positron emission tomography for the enrollee. 
 
You asked the Plan to provide coverage for this imaging. You say that this imaging is medically necessary. The 
Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that positron emission tomography 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 provide 
coverage for this imaging. Our reviewer says that Medicare criteria are not met. Our physician reviewer found 
the record indicates that the enrollee has increasing shortness of breath from worsened atrial fibrillation burden 
and has had a stress test with moderate ischemia in the left anterior descending artery distribution.  The record 
does not indicate that the requested test is to determine myocardial viability as a primary or initial diagnostic 
study prior to revascularization or following an inconclusive SPECT.  The elements of the coverage criteria are 
not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of this imaging have 
not been met. Therefore, we decided that the Plan does not have to provide coverage for positron emission 
tomography for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a thermal intermittent pneumatic compression device. 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the device is necessary to 
prevent deep vein thrombosis in an upcoming shoulder surgery. The Plan denied your request. The Plan says 
the device is necessary to prevent deep vein thrombosis after surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. You do not meet coverage criteria.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to preapprove a thermal intermittent pneumatic compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve battery backup for oxygen equipment for the enrollee. 
 
You asked the Plan to pre-approve battery backup. You say that this equipment is necessary in case of a power 
outage. The Plan denied your request. The Plan says battery packs for precautionary reasons are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  Battery packs for precautionary instances are not covered by Medicare. Therefore, we 
decided that the Plan does not have to pre-approve battery backup for oxygen equipment for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper dentures (D5110) and complete lower 
dentures (D5120). 
 
You asked the Plan to pre-approve complete upper dentures and complete lower dentures. You say that the 
items are necessary. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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 one complete 
upper and lower dentures every five plan years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of complete upper dentures and complete lower dentures have not been met. Specifically, the benefit 
was exhausted on January 3, 2020. Therefore, we decided that the Plan does not have to pre-approve complete 
upper dentures (D5110) and complete lower dentures (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peripheral nerve block identified with code 64450.
You asked the Plan to pre-approve a peripheral nerve block identified with code 64450. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested
services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that peripheral nerve blocks are non-covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a peripheral nerve block identified with code 64450 have not been met. We note that you might be
requesting a different procedure; however, the procedure code being requested (64450) is for a peripheral nerve
block and these are non-covered. The Plan has noted that if a different procedure was being requested that a
more appropriate code would need to be requested. Therefore, we decided that the Plan does not have to preapprove
a peripheral nerve block identified with code 64450.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network gynecological services. 
 
You asked the Plan to pre-approve out of network gynecological services. You say that you prefer to see the 
requested provider. The Plan denied your request. The Plan says these services can be provided 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 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 out of network 
gynecological services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmology 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 are several in-network ophthalmology specialists 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 to an out-of-network ophthalmology provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided to the enrollee on May 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5211) and a partial lower 
denture (D5212). 
 
You asked the Plan to pre-approve the dental items. You say that your current partial dentures do not fit. You 
say that you would like to go to a different provider. You also say that you do not want to be charged. The Plan 
denied your request. The Plan says partial dentures are covered once every 60 months, per arch. The Plan also 
says that the frequency limit has been reached. 
 
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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental items have not been met. Specifically, the frequency limit has been reached. The record 
shows that the Plan paid for partial dentures that you received on July 29, 2020. Therefore, we decided that the 
Plan does not have to pre-approve a partial upper denture (D5211) and a partial lower denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration. 
 
You asked the Plan to pre-approve biologic materials to aid in soft and osseous tissue regeneration. You say 
that this should be covered since it is part of the root canal treatment. The Plan denied your request. The Plan 
says the service is not a covered benefit. 
 
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 
biologic materials to aid in soft and osseous tissue regeneration.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921), localized delivery of microbial agents (D4381 x 2), bone replacement graft (D7953), partial upper denture (D5225), and an interim partial upper denture (D5820).
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says gingival irrigation, localized delivery of microbial agents, bone replacement graft, partial upper denture with flexible base, and interim partial upper denture are not listed as covered services.
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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921), localized delivery of microbial agents (D4381 x 2), bone replacement graft (D7953), partial upper denture (D5225), and an interim partial upper denture (D5820).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral evaluation and extraction with an oral surgeon.
You asked the Plan to pre-approve the extraction. You say that you have 2 nodules on the bone of the tooth. You also say that this is the last molar that needs to be removed so they can know what is going on with the bone. The Plan denied your request. The Plan says your supplemental dental benefit only provides coverage for dental services when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon 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, dental services performed by an oral
surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an oral evaluation and extraction with an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on March 19, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you asked if your benefits would allow for an out-
of-network purchase and you were informed you could submit a claim requesting reimbursement. You say that 
the devices purchased have compensated for your hearing loss and reimbursement should be approved. The 
Plan denied your request. The Plan says the hearing were not purchased from the Plan's hearing vendor. 
 
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 plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from the Plan's hearing aid vendor.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from the 
Plan's hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids 
provided on March 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure.
You asked the Plan to pre-approve the intracept procedure. You say that this surgery is medically necessary. The Plan denied your request. The Plan says this surgery is not covered by Medicare.
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 intracept procedure. Our physician reviewer found the intracept procedure 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional eyewear.
You asked the Plan to pre-approve additional eyewear. You say that you cannot see out of your current eyeglasses. You say you have had a loss of vision due to a sinus infection. The Plan denied your request. The Plan says you used your vision benefit on January 7, 2021, and you are not eligible for another pair of eyeglasses until January 1, 2022.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every year.
We looked at the file and the Plan's rules. The file shows that you received the routine eyewear benefit on January 7, 2021 and you are not eligible for another pair of eyeglasses this year. Based on this information, we decided that the Plan's rules for coverage of additional eyewear have not been met. Therefore, we decided that the Plan does not have to pre-approve additional eyewear.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine eye exam and eyeglasses.
You asked the Plan to pre-approve a routine eye exam and eyeglasses. You say that you cannot see out of the eyeglasses you received, and you are one point away from being blind in your left eye and need eyeglasses, which is why you have requested to reinstate your benefits. The Plan denied your request. The Plan says you
previously received a routine eye exam and eyeglasses that were covered under the supplemental vision care benefit and the benefit for these services/items is limited to one routine exam and one pair of eyeglasses per year.
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. We looked at the file and the Plan's rules. The file shows that you have used the vision benefit previously on January 26, 2021. The vision benefit is for one routine eye exam and one pair of eyeglasses per year. Therefore, we decided that the Plan does not have to pre-approve a routine eye exam and eyeglasses.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services. 
 
You asked the Plan to pre-approve out of network physician services. You say that you prefer to see the 
requested provider. The Plan denied your request. The Plan says this provider is not 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 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 out of network physician 
services.