Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says a request for a home mechanical ventilator set in average volume-assured pressure 
support (AVAPS) mode that could be delivered by bilateral positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
was recently hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (COPD). 
Exacerbation of congestive heart failure (CHF) may have also played a role, because the chest x-ray showed venous congestion. There was a mild elevation of partial pressure of carbon dioxide (PaCO2). There is no 
arterial blood gas (ABG) study done as an outpatient while awake and stable to confirm persistent hypercarbia. 
There are no pulmonary function tests to determine the severity of the COPD. Bilateral positive airway 
pressure (BiPAP) has not been tried at home. Medicare does not cover a home ventilator when used as BiPAP, 
and certain BiPAP devices can provide the AVAPS mode. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator for the enrollee.
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 are hypotensive, and you are not stable for 
transfer to a SNF. It is not medically reasonable and necessary to provide these skilled nursing or skilled 
therapy services on a daily basis. You do not require the necessary services on an inpatient basis, in a skilled 
nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive prediagnostic test (D0431) and filling (D2392) 
provided on October 6, 2021. 
 
You asked the Plan to pay for the dental services. You say that the staff should have asked if you wanted 
another set of x-rays. You say that you had already had x-rays done earlier in the year. You also say that the 
office did not give you any advance insurance payment notification and just proceeded with treatment. The 
Plan denied your request. The Plan says there is a $1,500 allowance for covered dental services. The Plan also 
says the maximum allowance has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum allowance has been 
exhausted. The record shows that the Plan paid $764 for services received on April 19, 2021, and $736 for 
services received on October 18, 2021. $764 + $736 = $1,500. Additionally, the Evidence of Coverage clearly 
states that you are responsible for any amount over and above the allowance amount. Therefore, we decided 
that the Plan does not have to pay for the adjunctive prediagnostic test (D0431) and filling (D2392) provided 
on October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services from January 4, 2022 through discharge.
You asked the Plan to pre-approve the inpatient psychiatric services. You say that you would like authorization
for services rendered in good faith from January 4, 2022 until discharge to be approved. The Plan denied your
request. The Plan says the inpatient psychiatric services you are requesting do not meet the requirements for approval.
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 inpatient psychiatric services. Our reviewer says that the psychiatric hospitalization is not medically reasonable and necessary for the enrollee Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This patient was compliant and cooperative with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. Our reviewer found that it did not appear that active treatment was taking place beyond the date in question. The record does not include an individualized treatment plan. Our physician reviewer also found that the services were supervised and evaluated by a physician. 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 inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services from January 4, 2022 through discharge.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2751) for tooth #20.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says that there is a cavity below the bone of your tooth. The Plan also says that the tooth will not last long because the cavity is below the bone.
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. Although it appears that dental x-rays were submitted to the Plan for review, the Plan did not forward these digital x-rays to us. Instead, poor quality photocopies of x-rays were submitted. We find that a photocopy of an x-ray is not a reasonable substitution for the original digital x-rays used by the Plan to makes its decision. For this reason, we find that the Plan failed to make a reasonable and diligent effort to substantiate its denial. Therefore, we decided that the Plan has to pre-approve a crown (D2751) for tooth #20.
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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. You say that you recommend Zilretta. The Plan denied your
request. The Plan says that there is not enough information in the medical journals that this type of long-acting
medication is better than the formulary medication for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 Zilretta. Our reviewer says that Zilretta
meets criteria for coverage. Our physician reviewer found Zilretta is an extended-release synthetic
corticosteroid which is indicated as an intra-articular injection for the management of osteoarthritis pain of the
knee. The enrollee has documented "terrible arthritis" of the knees, and treatment with Zilretta is considered
medically reasonable and necessary. Our physician reviewer also found that the documentation supports that
Zilretta would reasonably be expected to be safe and effective 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve
Zilretta.
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and 
interpretation (D0367). 
 
You asked the Plan to pre-approve the cone beam CT capture and interpretation. The Plan denied your request. 
The Plan says this service is not covered. 
 
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 a 
cone beam computed tomography (CT) capture and interpretation (D0367).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a glaucoma surgical aqueous drainage device (66989).
You asked the Plan to pre-approve a glaucoma surgical aqueous drainage device. You say that the service at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested service have not been met.
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 glaucoma surgical aqueous drainage device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee will be undergoing cataract surgery and has increased intraocular pressure. The record does not indicate that the enrollee is currently being treated with an ocular hypotensive medication. The elements of the coverage criteria are not satisfied. 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 glaucoma surgical aqueous drainage device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a glaucoma surgical aqueous drainage device (66989).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a Percutaneous Image-Guided Lumbar Decompression (PILD) 
procedure. 
 
You asked the Plan to pre-approve the requested PILD procedure. You say that the enrollee meets all criteria 
for this device which was found to be safe and effective in trials. The Plan denied your request. The Plan says 
that there is no evidence that the enrollee is participating in an approved clinical study. As such, this is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD may be covered when an enrollee is part of 
an approved clinical trial/study. 
 
In this case, the enrollee has documented LSS with neurogenic claudication. Though the Plan argues that there 
is no evidence of trial/study participation, this does not take into account one of the studies approved by 
Medicare. National Clinical Trial (NCT) number 03072927 automatically enrolls patients who receive this 
service/device and tracks outcomes per Medicare claims data. The inclusion criteria for the study include 
"Medicare beneficiaries for whom claims have been submitted to the Medicare Claims database and who have 
been enrolled in Medicare fee-for-service or Medicare Advantage for one year prior to their index procedure 
and two years post index procedure." 
 
Based on this information, the enrollee is not "participating" in the study until after the device has been placed, 
and the claims have been submitted. We find that since the only rationale used by the Plan is non-participation 
in a study, the denial is not substantiated. Therefore, we decided that the Plan has to pre-approve a 
Percutaneous Image-Guided Lumbar Decompression (PILD) procedure.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar decompression. 
 
You asked the Plan to pre-approve the lumbar decompression. You say that you submitted all necessary 
documentation. The Plan denied your request. The Plan says the request does not meet medical necessity 
criteria for the lumbar decompression. 
 
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 lumbar decompression. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is no documentation of adequate non-operative therapy such as 6 
weeks of recent physical 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 the lumbar decompression have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the lumbar decompression.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spectacle fitting (92340), and assessment (92015), 
provided on September 20, 2021. 
 
You asked the Plan to pay for the spectacle fitting and assessment. You say that the service should be covered. 
The Plan denied your request. The Plan says the member does not have out-of-network benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when obtained through a network provider. 
 
We looked at the file and the Plan's rules. services were obtained through an out-of-network provider. Based on 
this information, we decided that the Plan's rules for coverage of the spectacle fitting and assessment have not 
been met. Therefore, we decided that the Plan does not have to pay for the spectacle fitting (92340), and 
assessment (92015), provided on September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient spine surgery (CPT code(s) 22514 and 22515), for the enrollee.
You asked the Plan to pre-approve the outpatient spine surgery. You say that the services are medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 outpatient spine surgery. Our physician reviewer found the medical records do not show 25% or more vertebral body collapse and there is no documented degree of functional impairment. 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 outpatient spine surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the outpatient spine surgery (CPT code(s) 22514 and 22515), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical effectiveness of the requested service in the setting of spinal fusion surgery has not been demonstrated. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that bone marrow aspiration during spinal surgery was requested. The Plan has agreed to pre-
approve the lumbar decompression and fusion, with possible transforaminal lumbar interbody fusion (TLIF). 
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 requested services. Our physician 
reviewer found that bone marrow aspirate remains experimental in spine surgery when used as a bone graft. 
Therefore, the services are not considered medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271 x 800 units) and administration (96413 x 4 units).
You asked the Plan to pre-approve Keytruda. You say that the requested drug is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested single-agent Keytruda is not recommended for initial systemic therapy for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the requested drug Keytruda is not medically necessary. Our physician reviewer found the requested drug is being used as single agent first line chemotherapy. The reviewer found that the Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The reviewer found that the Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.
Therefore, the reviewer found that the requested drug and its associated administration are not considered medically reasonable or 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 Keytruda have not been met. Specifically, the file shows that the requested drug is not approved by the FDA for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271 x 800 units) and administration (96413 x 4 units).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on June 3, 2019. 
 
You asked the Plan to pay for the partial denture. You say that this claim was previously paid. You say that the 
provider returned the check to the plan. You also say that you feel you should not be responsible for the full 
amount of this bill. The Plan denied your request. The Plan says partial denture is not listed as 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the partial denture is not among those 
covered under this benefit. Additionally, the Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the partial upper denture (D5213) 
provided on June 3, 2019.