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

 
We decided that the Plan has to pre-approve a magnetic resonance imaging, breast, without and with contrast 
material(s), including Computer-Aided Detection (CAD real-time lesion detection, characterization, and 
pharmacokinetic analysis), when performed; bilateral. (77049). 
 
You asked the Plan to pre-approve an MRI breast, without and with contrast material(s), including Computer-
Aided Detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis), when 
performed; bilateral. The Plan denied your request. The Plan says that the enrollee does not meet the Medicare 
NCD coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI breast, without and with 
contrast material(s), including Computer-Aided Detection (CAD real-time lesion detection, characterization, 
and pharmacokinetic analysis), when performed; bilateral. Our reviewer says that an MRI breast, without and 
with contrast material(s), including Computer-Aided Detection (CAD real-time lesion detection, 
characterization, and pharmacokinetic analysis), when performed; bilateral is medically necessary. Our 
physician reviewer found that the last MRI showed increasing size and enhancement characteristics and 
importantly extension to the chest wall. An MRI is the best way to fully analyze the known cancer and to 
determine what type of therapy is indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI breast, without and with contrast material(s), including Computer-
Aided Detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis), when 
performed; bilateral have been met. Therefore, we decided that the Plan has to pre-approve a magnetic 
resonance imaging, breast, without and with contrast material(s), including Computer-Aided Detection (CAD 
real-time lesion detection, characterization, and pharmacokinetic analysis), when performed; bilateral. (77049).  
 
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: 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 requested admission to an IRF does not meet 
criteria. 
 
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 continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that he would 
meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee 
would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the 
supervision of a physician with at least 3 visits weekly to regain or maintain his functional status.  The enrollee 
can receive further services 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 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 the radiofrequency ablation at L3-L4. 
 
You asked the Plan to pre-approve the radiofrequency ablation at L3-L4. You say that you would like 
reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan 
says the notes do not show that member has had MBBs at this level. 
 
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 radiofrequency ablation at L3-L4. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found a radiofrequency ablation is considered medically reasonable and 
necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with 
each one providing a consistent minimum of 80% sustained relief of primary pain. The member has not had a 
previous injection at L3-L4. 
 
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 radiofrequency ablation at L3-L4 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the radiofrequency ablation at L3-L4.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a pontic (D6240) for tooth #10 and retainer crowns (D6750) for 
tooth #'s 9 and 11. 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that the enrollee is only missing 
two upper teeth. You also say that you were advised that a removable partial denture would not be covered to 
replace less than 8 teeth. The Plan denied your request. The Plan says that the information does not say why a 
denture cannot be used to replace the enrollee's missing 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 pontic and 
retainer crowns 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 pontic and retainer crowns. Our 
reviewer says that the documentation provided meets the criteria for coverage for a fixed bridge replacing 
missing tooth #10 with a pontic (D6240) using tooth #'s 9 and 11 as abutment retainers (D6750). Our physician 
reviewer found according to the criteria for coverage, a fixed bridge would be considered for coverage if the 
patient is in good oral health including good periodontal health and if the prognosis is favorable. Our reviewer 
also found that the documentation provided supports these criteria for this patient. 
 
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 pontic and retainer crowns have been met. Therefore, we decided that the 
Plan has to pre-approve a pontic (D6240) for tooth #10 and retainer crowns (D6750) for tooth #'s 9 and 11.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and psychotherapy provided by an opt out 
provider on October 7, 2021. 
 
You asked the Plan to pay for the office visit and psychotherapy. You say that your summary of benefits 
indicates 40% coinsurance for out of-network mental health services. You say that you will have to find a new 
provider if coverage will not be provided. The Plan denied your request. The Plan says the provider that 
performed the office visit services does not accept Medicare plans. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit and psychotherapy provided by an opt out provider on October 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transoral fundoplication (TIF) procedure for the 
enrollee. 
 
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 hiatal hernia is greater than 2cm. 
 
The Plan must follow Medicare rules. Medicare rules say that transoral fundoplication (TIF) procedures are not 
covered for any patient with a hiatal hernia greater than 2cm. 
 
The appeal letter shows that the hiatal hernia is 6cm in size. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transoral fundoplication (TIF) procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve monitored anesthesia care (MAC)/general anesthesia. 
 
You asked the Plan to pre-approve monitored anesthesia care (MAC)/general anesthesia. The Plan denied your 
request. The Plan says monitored anesthesia care (MAC)/general anesthesia 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 monitored anesthesia care 
(MAC)/general anesthesia. Our reviewer says that the requested monitored anesthesia care (MAC)/general 
anesthesia is not considered medically reasonable and necessary in this case. Our physician reviewer found that 
routine gastrointestinal endoscopy procedures in average-risk patients will usually not require anesthesiology 
assistance in the form of monitored anesthesia care or general anesthesia. According to the American Society 
of Anesthesiologists (ASA), a monitored anesthesia care (MAC) is a planned procedure during which the 
patient undergoes local anesthesia together with sedation and analgesia. The review has determined that this 
enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of 
MAC.  In this case, the enrollee has no significant past medical history to warrant MAC.  Patients with 
potential for difficult intubation and/or ventilation with a mask, or at risk for airway obstruction; Increased risk for complication due to severe co-morbidity. Although the enrollee was reported to have an ASA Class III 
physical status patients with chronic degenerative neurologic diseases which may cause difficulty swallowing 
or pose a risk for muscle weakness and respiratory failure; Morbid obesity (BMI>50); or Extremes of age, i.e., 
> 70 years of age or < 18, there is no documentation in the patient's record indicating that it is medically 
necessary to have an anesthesiologist present during the procedure. The review has determined that this 
enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of monitored anesthesia care (MAC)/general anesthesia have not been met. 
Therefore, we decided that the Plan does not have to pre-approve monitored anesthesia care (MAC)/general 
anesthesia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HFE (hemochromatosis) genetic testing. 
 
You asked the Plan to pre-approve HFE (hemochromatosis) genetic testing. You say that the requested HFE 
(hemochromatosis) genetic testing is medically necessary. The Plan denied your request. The Plan says the 
requested HFE (hemochromatosis) genetic testing 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 HFE (hemochromatosis) genetic 
testing. Our reviewer says that the requested HFE (hemochromatosis) genetic testing is not medically 
necessary. Our physician reviewer found the review indicates that the female enrollee has a history of history 
of diabetes mellitus, type II, joint pain, abdominal pain, infertility and gallbladder disease. She has a family 
history of hemochromatosis. She has no reported personal history or signs/symptoms of the disease. Her iron 
levels are normal. There is no specific clinical rationale for HFE (hemochromatosis) genetic testing. The 
review has determined that the requested HFE (hemochromatosis) genetic testing is not medically reasonable 
and necessary for the enrollee 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 HFE (hemochromatosis) genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve HFE (hemochromatosis) genetic testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hereditary cancer complete risk panel (81162, 81201, 
81209, 81218, 81235, 81236, 81242, 81272, 81292, 81295, 81298, 81317, 813231, 81334, 81403, 81404, 
81405, 81406, 81407, 81408, 81479) provided on January 6, 2020. 
 
You asked the Plan to pay for a hereditary cancer complete risk panel. You say that this is supported in the 
records. The Plan denied your request. The Plan says this is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a hereditary cancer complete risk panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for a hereditary cancer complete risk panel (81162, 81201, 81209, 81218, 81235, 81236, 
81242, 81272, 81292, 81295, 81298, 81317, 813231, 81334, 81403, 81404, 81405, 81406, 81407, 81408, 
81479) provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are asking the plan 
to approve additional rides beyond the 24 rides offered as you need rides to dialysis. You also say you have no 
way of getting to the appointments and cannot pay for rides. The Plan denied your request. The Plan says you 
have exceeded the maximum benefit for transportation trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. The file shows that you have used 24 one-
way transportation trips this year. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional non-emergent routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on November 28, 2021. 
 
You asked the Plan to pay for a telehealth visit. The Plan denied your request. The Plan says the provider did 
not submit medical records for the Plan to review for medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 a telehealth visit provided on 
November 28, 2021. have been met. The provider did not submit the medical records. Therefore, we decided 
that the Plan does not have to pay for a telehealth visit provided on November 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power wheelchair (K0801). 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says given the enrollee's weight of 256.6 pounds, the request does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that K0801 has a patient weight capacity of 301-450 
pounds. 
 
The enrollee's weight, at 256.6 pounds, is outside of the weight range for this request. Based on this 
information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 heavy duty power wheelchair (K0801).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you did not have any parental medications, 
complex wound care or nutrition given via a feeding tube. You were medically stable without any acute 
exacerbations of chronic medical problems. You did not require any skilled nursing or rehab services on a daily 
basis at an inpatient level of care. You were not expected to make measurable gains within a reasonable and 
predictable period of time or require skilled therapy to prevent deterioration with mobility or self-care tasks. 
You did not require skilled therapy to establish a safe and effective maintenance program.  As a practical 
matter, you did not require any skilled services on an inpatient basis, at a SNF level of care at the time of 
discharge from the hospital. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after April 21, 2022. 
 
You asked the Plan to pre-approve SNF care after April 21, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 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 care after April 21, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
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 care after April 21, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after April 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that this is needed since the enrollee needs to check his 
blood sugar multiple times per day. The Plan denied your request. The Plan says the criteria are not met as the 
enrollee does not use insulin. 
 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).