Persius/hicric huggingface dataset:
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 due to the extent of your critical illness myopathy 
you are at high risk for falling. You say that you currently require maximum assistance for ambulating and 
basic activities of daily living. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met at an alternate level of care. 
 
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 you have chronic needs and do not have complex or intensive rehabilitation 
needs. Your myopathy limits your ability to respond to intensive rehabilitation. You will need time to respond. 
You do not require frequent physiatry oversight. You may need close medical follow-up post-acute for your 
respiratory status, but the IRF is for intensive rehabilitation not a medical step down. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of split ear lobe. 
 
You asked the Plan to pre-approve repair of split ear lobe. You say that you have a right ear lobe that is split 
open from the top of the lobe all the way down and you feel that it needs to be repaired. The Plan denied your 
request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 repair of split ear lobe. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our reviewer found you have a split ear lobe due to re-piercing. The provided records do not document any 
functional impairment. The requested procedure is cosmetic, as defined by Medicare rules. Therefore, you do 
not meet criteria for the requested 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 repair of split ear lobe have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repair of split ear lobe.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure. 
 
You asked the Plan to pre-approve the VivAer procedure. You say that the VivAer procedure is medically 
necessary. The Plan denied your request. The Plan says the VivAer procedure is 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 the VivAer procedure. Our reviewer 
says that the requested the VivAer procedure is not considered medically reasonable and necessary. Our 
physician reviewer found that in this case, the medical record indicates that the enrollee has nasal congestion 
from turbinate hypertrophy and septal pathology. There is insufficient literature to support the safety and 
efficacy of the requested service for the enrollee's specific conditions. The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 the VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee is in pain and is scheduled for pain 
management. The Plan denied your request. The Plan says the requested MRI is not medically necessary. 
 
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 the MRI. Our reviewer says that the 
MRI of the lower extremity is not medically necessary. Our physician reviewer found that on the encounter 
date in July of 2022 there is mention of left trochanteric bursitis but no details concerning how that was 
diagnosed nor treatment for same. No plain films of the hips are in the submitted records. Physical exam of the 
extremities was unremarkable. The enrollee has no history of trauma and is not medicated with steroids. An 
MRI of the lumbar spine and sacroiliac (SI) joints were done on October 7, 2022. On the report of the SI joint 
MRI there is description of the piriformis muscles. It is very possible the hips were in the field of view of that 
SI joint MRI and the images of that exam should be review focusing on the hips to determine if further imaging 
of same is necessary. Based upon the information supplied in the records the medical necessity of the requested 
MRI of both hips has not been established in the records provided. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the biologic materials to aid in tissue regeneration in 
conjunction with periradicular surgery for tooth# 29 (D3431). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 Plans 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 the biologic 
materials to aid in tissue regeneration in conjunction with periradicular surgery for tooth# 29 (D3431).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on July 26, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the service was required prior to surgery. 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. This benefit includes the 
requested panoramic radiographic image (D0330) but is limited to one procedure every three plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested panoramic radiographic image (D0330) was exhausted on date of service 
January 12, 2021. Therefore, we decided that the Plan does not have to pay for panoramic radiographic image 
(D0330) provided on July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implanted loop recorder. 
 
You asked the Plan to pre-approve implanted loop recorder. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is only covered when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 implanted loop recorder. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found while you have a history of atrial fibrillation, there is no documentation provided 
to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in your 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implanted loop recorder have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implanted loop recorder.
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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition you do not meet all the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were evaluated for 
nausea, vomiting, and diarrhea and was discharged. There is ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical records support a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: 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. The Plan denied your request. The Plan says that the admission to 
an IRF is not medically necessary. 
 
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 clinical documentation shows that you do have complex functional 
impairments however, evaluating therapists recommend lower intensity therapy such as skilled nursing or  
 home health care. Therefore, you would not require intense therapy or expected to tolerate intense therapy of at 
least 15 hours per week. In addition, all your medical conditions have stabilized. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of pembrolizumab. 
 
You asked the Plan to pre-approve pembrolizumab. You say that this is medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 pembrolizumab. Our reviewer says that 
the enrollee does not meet the Medicare criteria for use of pembrolizumab. Our physician reviewer found 
pembrolizumab is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested 
use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-
approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pembrolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of pembrolizumab.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that you need this service and it has always been 
approved for four hours each day. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 the aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found you do not have 
documented skilled nursing or skilled therapy needs. Home health aide services are not shown to be necessary 
to assist in the treatment of an acute illness or injury.  
 The services are being requested on a daily, not intermittent basis and are not shown to be medically necessary, 
reasonable or coverable. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a core buildup (D2950) and crown restoration (D2750) for tooth 
number 4. We decided that the Plan does not have to pre-approve the core buildup (D2950) and crown 
restorations (D2750) to teeth numbers 12 and 13, nor the radiographic images (D0210). 
 
You asked the Plan to pre-approve a crown porcelain fused to high noble metal (D2750) for teeth numbers 4, 
12, and 13, core buildup, including any pins when required (D2950) for teeth numbers 4, 12, and 13, and 
intraoral - complete series of radiographic images (D0210). You say that these services will benefit the 
enrollee. The Plan says that this request does not meet criteria. 
 
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 crown porcelain fused to high noble 
metal (D2750) for teeth numbers 4, 12, and 13, core buildup, including any pins when required (D2950) for 
teeth numbers 4, 12, and 13, and intraoral - complete series of radiographic images (D0210). Our reviewer says 
that this partially meets criteria. Our physician reviewer found the documentation meets the criteria for 
coverage for a core buildup (D2950) and crown restoration for tooth number 4. Our physician reviewer also 
found that the criteria for coverage for core buildup and crown restorations to teeth numbers 12 and 13 have not 
been met. Our physician reviewer also says that radiographs taken after August 22 are not covered due to 
waiting period requirements. 
 
We decided that the Plan has to pre-approve a core buildup (D2950) and crown restoration (D2750) for 
tooth number 4.  
 
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 a core buildup (D2950) and crown restoration (D2750) for tooth number 4 have 
been met. Therefore, we decided that the Plan has to pre-approve a core buildup (D2950) and crown restoration 
(D2750) for tooth number 4.  
 
We also decided that the Plan does not have to pre-approve the core buildup (D2950) and crown 
restorations (D2750) to teeth numbers 12 and 13, nor the radiographic images (D0210). 
 
 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 core buildup (D2950) and crown restorations (D2750) to teeth numbers 12 
and 13, and the radiographic images (D0210) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the core buildup (D2950) and crown restorations (D2750) to teeth numbers 12 and 13, nor 
the radiographic images (D0210). 
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs warrant an IRF level of care to 
achieve a safe and sustainable discharge. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary. 
 
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 enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation.  The enrollees care needs can be met 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 3, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 3, 2022.