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

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the service. You say that you joined the plan due to dental and you haven't 
been able to use if for the past 2 years. You also say that you do not have enough teeth to eat which is causing 
you the health problems of not being able to digest food properly, causing you stomach issues. The Plan denied 
your request. The Plan says for this service to be approved the teeth that are left in your mouth must have a 
good long-term outcome. Based on the dentist x-ray, notes and pictures there are 1 or more teeth that are not 
healthy enough to support this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the service 
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 service. Our physician reviewer 
found the requested treatment under code D5214 is not medically necessary. The requested treatment is for a 
tooth supported appliance to replace missing teeth on the lower arch. In order to be able to function properly, 
the teeth used as supports need to have adequate bone anchorage. The supplied x-rays show that any of the 
abutment teeth that could be utilized have severe periodontal disease with accompanying loss of supporting 
bone. The teeth are inadequate to support the requested type of partial denture. Another type of partial denture 
that uses the soft tissues for support would be more appropriate and should be considered. 
 
The Plan would require that an appliance not harm the supporting teeth. A tooth supported partial denture, 
without adequate bone support on the abutment teeth, would weaken and loosen the teeth due to excessive 
forces being placed on the teeth. Given the radiographic evidence of bone loss on the abutment teeth, it would 
be inappropriate to use such an appliance on weakened anchor teeth that would degrade the remaining teeth and 
cause the appliance to fail in the end. The requested tooth supported partial denture would not meet the Plan 
criteria due to moderate to severe periodontal disease being present that would compromise the remaining 
natural teeth. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Heelex low-dose radiotherapy for plantar fasciitis.  
 
You asked the Plan to pre-approve the Heelex low-dose radiotherapy treatment. You say that randomized trials 
support the use of low-dose radiotherapy for plantar fasciitis as an alternative to steroid injections. The Plan 
denied your request. The Plan says there is not enough peer-reviewed evidence to support that the benefits of 
this treatment outweigh the risk, including secondary malignancy. 
 
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 Heelex low-dose radiotherapy 
treatment. Our reviewer says that the Heelex low-dose radiation treatment for this patients right painful plantar 
fasciitis is not medically reasonable or necessary. Our physician reviewer found the medical documentation 
supports that this patient has undergone minor conservative treatments for their plantar fasciitis, including stretching, icing, and rest with no relief. The patient has requested noninvasive treatments. The physician has 
recommended a Heelex low-dose radiation treatment. In this case, other more conservative treatments have not 
been exhausted. Further conservative treatments include physical therapy visits, custom orthotics, local steroid 
injections, anti-inflammatory medications, night splint, and or controlled ankle movement (CAM) boot 
immobilization.  
 
Endoscopic plantar fasciotomy (EPF) would be the standard of care after exhaustion of conservative 
management. The Heelex low-dose radiation treatment for plantar fasciitis is considered experimental in that it 
is not standard of care nor have there been significant studies to prove the efficacy of this treatment for painful 
plantar fasciitis. Therefore, it cannot be considered medically 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 the Heelex low-dose radiotherapy treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Heelex low-dose radiotherapy for plantar fasciitis.
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 enrollee feels that he is unable to get around and 
realizes that he needs a rehabilitation facility to facilitate physical and occupational rehabilitation. The Plan 
denied your request. The Plan says admission to an IRF is not reasonable and 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive rehabilitation physician or nursing oversight in an IRF. While the 
enrollee may benefit from additional therapy the documentation does not support that the enrollee requires this 
therapy on an intensive level in an acute inpatient rehabilitation 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 portable oxygen concentrator to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the in-network provider does 
not supply the specific portable oxygen concentrator you need. The Plan denied your request. The Plan says a 
portable oxygen concentrator is available in network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a portable oxygen concentrator to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Veltassa. 
 
You asked the Plan to pre-approve the medication. You say that this is necessary for the enrollee. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Veltassa.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary because based on the medical literature this procedure is considered experimental or 
investigational and has not been proven to be beneficial for the enrollee's condition. 
 
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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve 
block is experimental for 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 destruction by neurolytic agent, genicular nerve branches including imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA testing. 
 
You asked the Plan to pre-approve BRCA testing. 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 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 BRCA testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that you have a personal history of cancer. 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 BRCA testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA testing.
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 enrollee will require ongoing close medical 
supervision and management to prevent hospital readmission and of further medical decline. He remains at risk 
of de-compensation due to his acute and chronic co-morbid conditions. The Plan denied your request. The Plan 
says admission to an IRF is not reasonable and 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive rehabilitation physician or nursing oversight in an IRF. The enrollee's 
functional level does not require treatment by multiple therapies including physical or occupational therapy in 
an intensive rehabilitation program in an IRF. While the enrollee may benefit from additional therapy the 
documentation does not support that the enrollee requires this therapy on an IRF level.  
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve esophagus, gastroesophageal reflux test; with mucosal attached 
telemetry pH electrode placement, recording, analysis and interpretation (91035). 
 
You asked the Plan to pre-approve esophagus, gastroesophageal reflux test; with mucosal attached telemetry 
pH electrode placement, recording, analysis and interpretation. You say that this is medically necessary. The 
Plan denied your request. The Plan says that Medicare does not allow coverage under the enrollee's specific 
medical circumstances. 
 
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 esophagus, gastroesophageal reflux 
test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found this should be covered as it is to confirm the need for surgical intervention prior 
to hiatal hernia repair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH 
electrode placement, recording, analysis and interpretation have been met. Therefore, we decided that the Plan 
has to pre-approve esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode 
placement, recording, analysis and interpretation (91035).  
 
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: 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 you require an extension of SNF care. The Plan 
denied your request. The Plan says the requested continued SNF care does not meet the requirements for 
approval. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 skilled nursing facility (SNF) care.
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 cannot lift your right leg and require 
rehabilitation to regain mobility in your leg. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 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 continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the continuous glucose monitor. Our 
reviewer says that this device is not medically necessary. Our physician reviewer found the records do not 
show that the enrollee is using insulin or that the enrollee has a history of problematic hypoglycemia. 
 
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 continuous glucose monitor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator. Our physician 
reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive 
pulmonary disease. The record indicates that the enrollee is being treated with a device in average volume-
assured pressure support (AVAPS) mode. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability and failure of such a device has not been 
documented. Furthermore, ventilators fall under the Frequent and Substantial Servicing (FSS) payment 
category, and payment policy requirements preclude FSS payment for devices used to deliver continuous 
and/or intermittent positive airway pressure, regardless of the illness treated by the device. The elements of the 
coverage criteria are not satisfied. The requested service cannot be 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).