Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown restoration for tooth #18 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the dental advisor states that the tooth could be restored with an amalgam or resin 
restoration. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the services 
when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested crown restoration is medically reasonable or necessary. Our physician reviewer found that a review 
of the documentation indicates that tooth #18 has a large restoration with recurrent caries and a crack. A crown 
restoration is medically reasonable and necessary to restore tooth #18 to adequate masticatory function. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve a crown restoration for tooth #18  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) visits (97110, 97140, 97530). 
 
You asked the Plan to pre-approve PT visits. You say that your pelvic muscle has been through trauma. The 
request for PT is to help stretch the pelvic muscle as well as relax and teach you how to get back to normal. 
The therapist is helping you find the right solution to correct your problem. You also say you have pain in your 
lower abdomen, which the therapist was treating. The Plan denied your request. The Plan says two requests 
were made for the same therapy services request. The first request was approved by the Plan. Despite multiple 
requests, records have not been received to establish why additional therapy services are required. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of physical therapy (PT) visits (97110, 
97140, 97530). have been met. The records show that the Plan received two requests for PT. The records also 
show that the Plan approved PT visits upon the first request. Additional medical records were requested and not 
received. As such, it cannot be confirmed why additional therapy services are required. Therefore, we decided 
that the Plan does not have to pre-approve physical therapy (PT) visits (97110, 97140, 97530).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on October 14, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that the service should deny as noncovered 
services with enrollee liable for full charges. The Plan denied your request. The Plan says since there was no 
transport, there are no payable services provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 14, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that the facility wants the enrollee to be 
as independent as possible. The Plan denied your request. The Plan says power wheelchairs in a nursing facility 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
We looked at the file and the rules. The records show that the requested wheelchair is being requested for use 
in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS) 
therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that TENS therapy for Chronic Low Back Pain (CLBP) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The file shows that the TENS therapy is being requested for the 
treatment of CLBP. The services are not covered for this indication. Therefore, we decided that the Plan does 
not have to pre-approve transcutaneous electrical nerve stimulation (TENS) therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiology services (33990) provided June 15, 2021 to June 
17, 2021. 
 
You asked the Plan to pay for the cardiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 33990 is not supported in the medical record. Specifically, the claim did not include a 
valid diagnosis code for this service. Based on this information, we decided that Medicare rules for coverage of 
the cardiology services have not been met. Therefore, we decided that the Plan does not have to pay for 
cardiology services (33990) provided June 15, 2021 to June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
required criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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.  
 
 The enrollee would benefit from close medical monitoring with complex past medical history and resolving 
hospital complications however evaluating therapists specifically document poor tolerability and recommend a 
less intense setting of skilled therapy. Therefore, the patient is unlikely to be able to tolerate or benefit from an 
intense interdisciplinary rehabilitation program in an IRF setting. Our physician reviewer found that your 
condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on September 
12, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the diagnosis is not valid with the procedure billed. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the record 
indicates that the enrollee was transported to the hospital with a two week history of epigastric burning type 
pain. The record indicates that the enrollee was transported via stretcher. The record does not indicate that 
the patient's clinical condition is such that other methods of transportation, such as stretcher van are 
contraindicated. Furthermore, a prudent layperson would not consider such symptoms an imminent threat to 
health. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on September 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excision of excessive skin and subcutaneous tissue of 
the arm (15836). 
 
You asked the Plan to pre-approve an excision of excessive skin and subcutaneous tissue of the arm. You say 
that the requested service is a medical necessity for you. The Plan denied your request. The Plan says rules for 
coverage have not been met because the requested service is cosmetic in this case. 
 
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 an excision of excessive skin and 
subcutaneous tissue of the arm. Our reviewer says that the requested service is not medically reasonable and 
necessary in this case. Our reviewer found that the record indicates that you have had weight loss following 
bariatric surgery. The record does not indicate the failure of conservative treatments for excessive arm skin or 
that there is a functional impairment present. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an excision of excessive skin and subcutaneous tissue of the arm have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an excision of excessive skin and 
subcutaneous tissue of the arm (15836).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the 
enrollee on July 19, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this denial was appropriate given the clinical scenario. 
 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no Medicare benefit for screening cardiovascular risk assessment testing for asymptomatic 
(without signs or symptoms of disease) patients. Screening asymptomatic patients for cardiovascular risk is 
statutorily excluded by Medicare. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiovascular risk assessment testing provided to the enrollee on July 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the 
enrollee on October 21, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the services were initiated by the laboratory and not by the doctor. The laboratory has provided the primary care physician input directly from the patient pathologist notes and other documentation 
related to her personal and/or family cardiovascular history that she may have hereditary cardiac risk 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiovascular risk assessment testing provided to the enrollee on October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and have no medical complexity and do not need PM&R 
physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. Thus, you do not need 3 hours a day five days a week of 
IRF therapies with interdisciplinary management. While you may benefit from physical therapy, and 
occupational therapy, your rehab needs can be addressed at a low intensity alternate setting such as in a skilled 
nursing facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane (nab-paclitaxel) (J9264). 
 
You asked the Plan to pre-approve Abraxane. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Taxol (paclitaxel) 
or Taxotere (docetaxel). 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Abraxane. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the medical records provided do not 
indicate that the enrollee has tried and failed the required drugs, Taxol or Taxotere. The reviewer found that the 
provided records do not indicate that the plan's required drugs would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abraxane (nab-paclitaxel) (J9264).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot, ankle features, 
and extra covering. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says an advanced foot and extra protective prosthetic cover were requested but does not meet 
Medicare criteria as reasonable and 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is inadequate documentation to support that you are a K3 ambulator to meet Medicare criteria for 
the requested prosthetic leg with advanced foot and ankle features. At the time of the examination, you were 
non-weight bearing with the right lower extremity, and using crutches or a wheelchair. For your initial 
prosthesis after the amputation, the provided records do not clarify why the advanced foot and ankle features 
are medically necessary as opposed to a K2 level device. Additionally, there is no documentation in the treating 
practitioner's medical notes that clarifies that you have special needs for protection against unusually harsh 
environments to meet Medicare criteria for the requested extra covering. 
 
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 a prosthetic leg with an advanced foot, ankle features, and extra covering.