Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Insertion or replacement of permanent implantable 
defibrillator system, with transvenous lead(s), single or dual chamber (33249) and Intracardiac catheter ablation 
of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or 
without temporary pacemaker placement (93650) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records show the enrollee does not have severe cardiomyopathy 
with an ejection fraction less than or equal to 35%, and the enrollee does not have an indication for replacement 
of the automatic implantable cardioverter-defibrillator (AICD). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patients most 
recent ejection fraction on 6/23/2022 was 45-50%. An attempt at catheter ablation of atrial fibrillation was 
made but could not be performed because of technical difficulties. Further attempts at rate control of atrial 
fibrillation have not been made. As such, the patient does not meet guideline criteria for upgrade to an 
implantable cardiac resynchronization therapy (CRT) defibrillator. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Insertion or replacement of permanent implantable defibrillator system, with transvenous 
lead(s), single or dual chamber (33249) and Intracardiac catheter ablation of atrioventricular node function, 
atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker 
placement (93650) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that physical therapy is medically necessary. The 
Plan denied your request. The Plan says an additional 12 physical therapy visits are not medically necessary. 
 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 therapy 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 need for ongoing additional skilled therapy cannot be 
determined without the outcome of the already approved therapy and without evidence of ongoing skilled 
therapy needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 12 physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported maxillary denture (D6110). 
 
You asked the Plan to pre-approve the dental services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 5, 2019. Therefore, 
we decided that the Plan does not have to pre-approve an implant supported maxillary denture (D6110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (CPT code E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the full electric hospital bed would 
help you maneuver around. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (CPT code E0265).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you need additional therapy and wound care. The 
Plan denied your request. The Plan says you have not had a change in function warranting daily skilled therapy. 
 
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 SNF 
care is not medically reasonable and necessary. Our physician reviewer found that 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 
skilled nursing facility (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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulator. 
 
You asked the Plan to pre-approve a peripheral nerve stimulator. You say that the requested peripheral nerve 
stimulator for right knee pain is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for the requested peripheral nerve stimulator for right knee pain. 
 
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 peripheral nerve stimulator. Our 
reviewer says that the enrollee does not meet criteria for the requested peripheral nerve stimulator for right knee pain. Our physician reviewer found detailed documentation is not evident regarding trial and failure of 
recent, reasonable, and comprehensive less invasive conservative care measures. The device is not clearly 
documented to be a last resort treatment modality. Additionally, there is no documentation of a careful 
screening, evaluation and diagnosis by a multidisciplinary team (including psychological and physical 
evaluation) prior to implantation. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the enrollee does not meet the 
NCD criteria for the requested peripheral nerve stimulator for right knee pain. 
 
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 peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a peripheral nerve stimulator.
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 need IRF care. The Plan denied your request. 
The Plan says medical necessity rules for IRF care 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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy and sclerotherapy. 
 
You asked the Plan to pre-approve stab phlebectomy and sclerotherapy. You say that stab phlebectomy and 
sclerotherapy is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 stab phlebectomy and sclerotherapy. 
Our reviewer says that stab phlebectomy and sclerotherapy is not medically necessary. Our physician reviewer 
found the record indicates that the enrollee has varicose veins with saphenous reflux that has yet to be treated.  The elements of the coverage criteria are not satisfied. The requested service is not 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 stab phlebectomy and sclerotherapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve stab phlebectomy and sclerotherapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified oral surgery procedure (D7999) and deep 
sedation (D9222, D9223) provided on February 21, 2022. 
 
You asked the Plan to pay for oral surgery and sedation. You say that these services were medically necessary. 
The Plan denied your request. The Plan says an unspecified oral surgery procedure (D7999) and deep sedation 
(D9222, D9223) are not covered by your dental 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 an 
unspecified oral surgery procedure (D7999) and deep sedation (D9222, D9223) provided on February 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional non-emergent transportation trips. 
 
You asked the Plan to pre-approve 8 additional trips. You say that you need additional trips. The Plan denied 
your request. The Plan says additional trips that exceed the allowed number per year are not covered. 
 
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 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 8 additional non-emergent transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment-includes modification and 
placement (D6056) and an implant supported porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy. 
 
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 are not among 
those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pre-approve a prefabricated abutment-includes 
modification and placement (D6056) and an implant supported porcelain/ceramic crown (D6065).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a long-term acute care hospital (LTACH) admission. 
 
You asked the Plan to pre-approve the LTACH admission. You say that the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the LTACH admission 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 admission. Our reviewer 
says that the requested LTACH admission is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates that the enrollee does not require services 
at the LTACH that are not already available at the current facility. Therefore, the reviewer found that transfer to 
the LTACH is not medically necessary at this time as it would not be clinically advantageous. 
 
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 admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a long-term acute care hospital (LTACH) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4260) and sedation (D9243) provided on 
December 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your annual allowance for dental services has been met. The Plan 
also says that sedation (D9243) is not covered by your dental 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. 
 
The record shows your annual allowance for dental services has been met. Though the Plan offers a dental 
benefit in excess of Medicare coverage, sedation (D9243) is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for osseous surgery (D4260) and sedation (D9243) 
provided on December 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy (HBOT). You say that the requested hyperbaric 
oxygen therapy (HBOT) is medically necessary. The Plan denied your request. The Plan says the requested 
hyperbaric oxygen therapy (HBOT) 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 hyperbaric oxygen therapy (HBOT). 
Our reviewer says that the requested hyperbaric oxygen therapy (HBOT) is not medically necessary. Our 
physician reviewer found neither prostate cancer nor memory loss qualifies for hyperbaric oxygen therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy (HBOT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 8, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that this is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested device is 
considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient literature in the peer reviewed publications to assess 
safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for 
upper extremity paralysis/paresis from conditions such as the patient's brachial plexus injury, or other  
neuromuscular/neurological disease or injury. The requested device is not the standard of care for the patient's 
condition and therefore not reasonable and 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 a MyoPro Motion G orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G orthosis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoride varnish (D1206) and periodontal maintenance 
(D4910) provided by a participating provider provided on March 7, 2022. 
 
You asked the Plan to pay for fluoride varnish and periodontal maintenance. You say that you do not 
understand why you are being charged $128. The Plan denied your request. The Plan says the benefit limit for 
dental services has already been met and exhausted. 
 
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 fluoride 
varnish and periodontal maintenance when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that the annual dental allowance 
amount has already been met and exhausted. Based on this information, we decided that the Plan's rules for 
coverage of fluoride varnish and periodontal maintenance have not been met. Therefore, we decided that the 
Plan does not have to pay for fluoride varnish (D1206) and periodontal maintenance (D4910) provided by a 
participating provider provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing in four quadrants (D4341).

You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental services. The Plan denied your request. The Plan says your benefit for the requested item or service has already 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service December 16, 2020, and December 21, 2020. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing in four quadrants (D4341).