Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted musculoskeletal surgical navigational 
orthopedic procedure, with image guidance (CPT code 0055T-RT) and an inpatient admission to be associated 
with an elective right total knee arthroplasty. 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says you are medically stable and has been provided medical clearance to 
undergo this elective procedure. The Plan states the planned procedure listed under CPT code 27447 is not 
listed on the CMS Inpatient Only List and the procedure is currently approved as an ambulatory procedure. The 
Plan states there is no documentation provided to support the expectation that you will require a greater than a 
two (2) midnight stay. The Plan states if you experience any peri- or post- operative complications, 
reconsideration for inpatient level of care can be performed on concurrent review with updated clinical 
information. The Plan states there is lack of reliable evidence in the medical literature to show that a computer-
assisted musculoskeletal surgical navigation improves surgical outcomes for knee arthroplasty. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found computer navigation is not needed for routine total knee replacement (TKR) surgery. A forty-
eight (48) hour overnight stay is also not needed based on the records. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image 
guidance (CPT code 0055T-RT) and an inpatient admission to be associated with an elective right total knee 
arthroplasty.
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 are living in a trailer, and it is getting harder for 
the enrollee to move around. You state you were recently in the emergency room and have become sick. You 
state that you do not want to end up bed bound and lose your ability to care for yourself. The Plan denied your 
request. The Plan says the stay is not medically necessary based on IRF 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 you are medically stable and does not need Physical Medicine and Rehabilitation 
(PM&R) physician close supervision three (3) times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No rehabilitation nursing needs identified or 
documented in the record. You do not need 3 hours a day five (5) days a week of IRF therapies with 
interdisciplinary management and the needs can be met in an alternate and lower setting such as in a skilled 
nursing facility (SNF). You need routine physical therapy (PT) and occupational therapy (OT). IRF admission 
is not medically necessary based on medical stability, lack of medical complexity, and lack of rehabilitation 
nursing needs. Document does not support the necessity for admission to an IRF. While you may benefit from 
PT, and OT, your rehabilitation can be safely provided at a lower intensity and alternate setting such as in an 
SNF. 
 
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 pay for the open treatment of radial and ulnar shaft fractures (25575) 
provided on May 8, 2021. 
 
You asked the Plan to pay for the open treatment of radial and ulnar shaft fractures (25575). You say that 
medical records are attached to process the claim for payment. The Plan denied your request. The Plan says this 
service was previously paid on November 18, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be an exact duplicate are rejected and do not have appeal rights. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this claim for the open treatment of radial and ulnar shaft fractures (25575) have not been met. 
Therefore, we decided that the Plan does not have to pay for the open treatment of radial and ulnar shaft 
fractures (25575) provided on May 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa 75 mg tablet. 
 
You asked the Plan to pre-approve Gemtesa. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the 
enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa 75 mg tablet.  
 
Benefits for Gemtesa 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide-Formoterol HFA inhaler. 
 
You asked the Plan to pre-approve Budesonide-Formoterol. You say that this drug is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the 
enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Budesonide-Formoterol 
HFA inhaler.  
 Benefits for Budesonide-Formoterol 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that ongoing physical therapy is medically 
necessary for this enrollee. The Plan denied your request. The Plan says the additional physical therapy is not 
medically necessary in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has previously been treated with outpatient therapies 
and should be independent with a home exercise program. There is no documentation of a recent injury or 
decline in function. The additional therapy services are not an appropriate duration and frequency for treatment 
of the enrollees medical condition and therefore are 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 24 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and resin-based composite (D2392) provided from June 24, 2021, to July 8, 2021 by a Medicare opt out 
provider. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and resin-based composite. You say 
that according to your insurance, you are to be reimbursed for dental expenses. The Plan denied your request. 
The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan 
also says that you did not contact the Plan prior to receiving these services, and the treating provider opted out 
of Medicare effective July 7, 2006, to July 7, 2022. 
 
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 
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and resin-based 
composite (D2392) provided from June 24, 2021, to July 8, 2021 by a Medicare opt out provider.
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 the enrollee needs physical therapy and occupational 
therapy. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF 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 is medically stable and did not need Physical Medicine and 
Rehabilitation (PM&R) physician close supervision three (3) times per week (at a minimum) since April 19, 
2022, for the ongoing management of any active or acute exacerbations of chronic medical conditions. No 
rehabilitation nursing needs identified or documented in the record. At the functional level, the enrollee did not need three (3) hours a day five (5) days a week of IRF therapies with interdisciplinary management and the 
needs can be met in an alternate and lower setting such as in a skilled nursing facility (SNF). IRF admission 
was not medically necessary based on medical stability, lack of medical complexity, and lack of rehabilitation 
nursing needs. Document did not support the necessity for admission to an IRF. While the enrollee may have 
benefitted from physical therapy (PT), and occupational therapy (OT), the enrollee's rehabilitation could have 
been safely provided at a lower intensity and alternate setting such as in an SNF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cystourethroscopy, with insertion of temporary prostatic 
implant/stent with fixation/anchor and incisional struts-the iTind procedure. 
 
You asked the Plan to pre-approve cystourethroscopy, with insertion of temporary prostatic implant/stent with 
fixation/anchor and incisional struts-the iTind procedure. The Plan denied your request. The Plan says 
cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts 
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 cystourethroscopy, with insertion of 
temporary prostatic implant/stent with fixation/anchor and incisional struts-the iTind procedure. Our reviewer 
says that the requested the iTind procedure not considered medically reasonable and necessary in this case. Our physician reviewer found that the iTind procedure is not medically reasonable and necessary in this case 
and is not given a recommendation in the current American Urological Association guidelines. Further studies 
are needed to evaluate the durability of iTind outcomes over a longer follow-up to better define the indications 
of this approach, and to demonstrate the advantages of second-generation device over the first. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cystourethroscopy, with insertion of temporary prostatic implant/stent with 
fixation/anchor and incisional struts-the iTind procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve cystourethroscopy, with insertion of temporary prostatic implant/stent with 
fixation/anchor and incisional struts-the iTind procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
provided October 7, 2021. 
 
You asked the Plan to pay for the periapical x-ray. You say that you are no longer opted-out of Medicare and 
the enrollee's claim should be reprocessed. The Plan denied your request. The Plan says this service is not 
covered under the enrollee's benefits. 
 
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 the 
intraoral - periapical first radiographic image (D0220) provided October 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on December 9, 2021. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that there is authorization on file for these 
services. The Plan denied your request. The Plan says the payment for this service is always bundled into the 
payment for another service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rebase complete maxillary denture (D5710) and rebase 
complete mandibular denture (D5711). 
 
You asked the Plan to pre-approve rebase complete upper and lower dentures. You say that a rebase of the 
dentures would greatly benefit the enrollee. The Plan denied your request. The Plan says this service is not 
covered under the enrollee's benefits. 
 
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 pre-approve 
rebase complete maxillary denture (D5710) and rebase complete mandibular denture (D5711).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implants 
(D6010), custom fabricated abutments - includes placement (D6057), and implant supported porcelain/ceramic 
crowns (D6065). 
 
You asked the Plan to pre-approve endosteal implants, custom fabricated abutments and implant supported 
crowns. You say that you would like these services covered. The Plan denied your request. The Plan says 
implant services are not covered under your benefits. 
 
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 
surgical placement of implant body: endosteal implants (D6010), custom fabricated abutments - includes 
placement (D6057), and implant supported porcelain/ceramic crowns (D6065).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 20, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the ordering physician must clearly document, in 
the medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. The records provided do not contain 
documentation of the ordering physicians intent that the tests be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the battery (A4235), lancing device (A4258), lancets 
(A4259), test strips (A4253), and control solution (A4256). 
 
You asked the Plan to pay for the diabetic supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says there is insufficient documentation. 
 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The signed physician order was dated after the 
date the member received the items, neither the packing slip or proof of delivery match the date of service and 
there are no medical records to determine medical necessity of these items. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the battery (A4235), lancing device (A4258), lancets (A4259), test strips 
(A4253), and control solution (A4256).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided November 24, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you feel this should be covered because it 
was an emergency. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
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. The Plan covers oral exams 
once every 6 months.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on July 23, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation - problem focused (D0140) provided November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921) and drugs or 
medicaments dispensed in the office for home use (D9630) provided February 7, 2022. 
 
You asked the Plan to pay for the gingival irrigation and drugs dispensed in the office for home use. You say 
that these services were necessary, and you cannot afford the cost. The Plan denied your request. The Plan says 
these services are not covered under your benefits. 
 
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 pay for the 
gingival irrigation - per quadrant (D4921) and drugs or medicaments dispensed in the office for home use 
(D9630) provided February 7, 2022.