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 services are medically necessary due to your 
medical needs and weakness. The Plan denied your request. The Plan says the services you need can be 
provided safely in another setting such as a skilled nursing facility, home with home health services or home 
with outpatient therapy. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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 minuteman procedure. 
 
You asked the Plan to pre-approve a minuteman procedure. You say that the service is 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 pre-approve a minuteman procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. There are multiple alternate pain generators plausibly significantly contributing to the clinical condition that have not been fully documented as having been excluded and/or ruled out. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a minuteman procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
for admission to an IRF. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation-new or established 
patient (D0180), limited oral evaluation-problem focused (D0140) and intraoral-periapical first radiographic 
image (D0220) provided on August 29, 2022, to September 6, 2022. 
 
You asked the Plan to pay for evaluations and imaging. You say that this should be covered. The Plan denied 
your request. The Plan says these are not covered services. 
 
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 
comprehensive periodontal evaluation-new or established patient (D0180), limited oral evaluation-problem focused (D0140) and intraoral-periapical first radiographic image (D0220) provided on August 29, 2022, to 
September 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Posterior Tibial Nerve Stimulation (PTNS) (64566). 
 
You asked the Plan to pre-approve a Posterior Tibial Nerve Stimulation (PTNS). You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service 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 Posterior Tibial Nerve Stimulation 
(PTNS). Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found he records show that this enrollee has neurogenic bladder and detrusor 
areflexia. PTNS treatments are indicated for treatment for patients with symptomatic non-neurogenic 
overactive bladder and nonobstructive urinary retention, following failed conservative therapy and 
pharmacotherapy.  
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 Posterior Tibial Nerve Stimulation (PTNS) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Posterior Tibial Nerve Stimulation (PTNS) (64566).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you feel you are entitled to this benefit, as you 
have diabetes, depression, schizophrenia, and high blood pressure. The Plan denied your request. The Plan says 
based on the information submitted, there is no documentation that you meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan made multiple attempts to 
obtain this information, but it was not received. Without medical records, we are unable to determine if you 
meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the requested drug was approved under Medicare Part 
D. You also say that the requested drug is medically necessary for the enrollee. The Plan denied your request. 
The Plan says drugs supplied by a pharmacy are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox (J0585).  
 
Benefits for Botox may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the Apple watch (A9300) purchased on December 6, 
2022. 
 You asked the Plan to pay more for the Apple watch. You say that you submitted your reimbursement last year 
and were reimbursed. You also say if the policy changed, you should have been notified. The Plan denied your 
request. The Plan says you have already been reimbursed a total of $200 toward your Wellness Allowance 
benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. However, the Plan offers a Wellness Wallet benefit that exceeds Medicare coverage. For that 
reason, the Plans coverage rules apply in this case.  
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. However, the 
Plan offers an annual $200 wellness allowance for you to use toward specific items and services. The record 
shows that you have met this maximum allowance. Therefore, we decided that the Plan does not have to pay 
more for the Apple watch (A9300) purchased on December 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic item L5910. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request does not meet coverage criteria. 
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee currently has an alignable system (L5910). The enrollees current system 
serves the same purpose as the requested services. The records do not show that the current system is unable to 
be used based on Medicare guidelines for replacement. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve prosthetic item L5910.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on January 6, 2023. 
 
You asked the Plan to pay for panoramic x-ray. You say that this should be covered. The Plan denied your 
request. The Plan says this 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 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 
panoramic x-ray (D0330) provided on January 6, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the hearing aids (V5298 x 2) purchased on April 5, 
2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says that the hearing aids in this case 
are not payable as they were purchased from an out-of-network provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that the hearing aids in this case are not payable 
as they were purchased from an out-of-network provider. However, the provider information submitted by the 
Plan was not indicated correctly in the documentation provided. Therefore, we are unable to determine the 
allowable coverage of the items purchased in this case. The Plan has not substantiated their denial; therefore, 
we must find in your favor. Therefore, we decided that the Plan has to issue reimbursement for the hearing aids  
(V5298 x 2) purchased on April 5, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 6, 2022, billed 
with codes 81201, 81298, 81307, 81317, 81321, 81351, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that the lab services were medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 6, 2022, billed with codes 81201, 81298, 81307, 81317, 81321, 81351, and 81272.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical removal of residual tooth roots (D7250) provided on 
June 9, 2022. 
 
You asked the Plan to pay for surgical removal of residual tooth roots. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 surgical 
removal of residual tooth roots (D7250) provided on June 9, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the partial hospitalization program. 
 
You asked the Plan to pre-approve the partial hospitalization program. You say that the service is medically 
necessary. The Plan denied your request. The Plan says you  can be safely managed on an outpatient basis with 
increased frequency of visits with your psychiatrist for review/optimization of pharmacotherapy and 
psychological treatment to cope with psychosocial stressors and management of interpersonal conflicts with 
neighbors.  
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 the partial hospitalization program. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that it did not appear 
medically necessary and reasonable to have psychiatric care provided at the partial hospitalization level of care 
rather than a lower level of care as you did not have any suicidal or homicidal thoughts or behavioral 
disturbance and your symptomatology could be treated at a lower 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 the partial hospitalization program have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the partial hospitalization program.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography (codes 93456, 93457, 93458, 93459, 93460, and 93461), left heart catheterization (93462), 
pharmacologic agent administration (93463), physiologic exercise study (93464), and an injection procedure 
during cardiac catheterization (93566). 
 
  You asked the Plan to pre-approve a catheter placement in coronary artery(s) for coronary angiography, left 
heart catheterization, pharmacologic agent administration, physiologic exercise study, and an injection 
procedure. You say that you would like the records to be reviewed so that an approval for this procedure can be 
obtained. The Plan denied your request. The Plan says no unique circumstances were found that would allow 
for an exception to approve the requested insertion for an of a catheter in coronary arteries. The Plan also says 
that the services cannot be approved as 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 catheter placement in coronary 
artery(s) for coronary angiography, left heart catheterization, pharmacologic agent administration, physiologic 
exercise study, and an injection procedure. Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of 
inferior infarct, and recent radionuclide stress test showed evidence of previous infarct and mild peri-infarct 
ischemia. The enrollee has been asymptomatic for the past 6 months. Our reviewer found that the guidelines do 
not support a need for cardiac catheterization/percutaneous coronary intervention in this setting. Our physician 
reviewer also found that as a result, at this time cardiac catheterization would not be considered medically 
appropriate and necessary in this enrollees clinical management. 
 
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 catheter placement in coronary artery(s) for coronary angiography, left heart 
catheterization, pharmacologic agent administration, physiologic exercise study, and an injection procedure 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a catheter placement in 
coronary artery(s) for coronary angiography (codes 93456, 93457, 93458, 93459, 93460, and 93461), left heart 
catheterization (93462), pharmacologic agent administration (93463), physiologic exercise study (93464), and 
an injection procedure during cardiac catheterization (93566).