Persius/hicric huggingface dataset:
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a caudal epidural steroid injection (ESI). 
 
You asked the Plan to pay for a caudal ESI. You say that this is supported in the records. The Plan denied your 
request. The Plan says this request exceeds the maximum sessions allowed in a twelve-month period. 
 
The Plan must follow Medicare rules. Medicare rules say that ESIs are limited to a maximum of four sessions 
per spinal region in a rolling twelve-month period. 
 
We looked at the file and Medicare rules. The record shows that the enrollee has had four caudal ESIs in the 
previous twelve months. Based on this information, we decided that Medicare rules for coverage of a caudal 
ESI have not been met. Therefore, we decided that the Plan does not have to pay for a caudal epidural steroid 
injection (ESI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for 
admission to an IRF.  
 
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 does not specify any acute complex functional 
impairments or active medical comorbidities. Thus, the complexity of the enrollee's documented nursing, 
medical, and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The clinical documentation shows that the enrollee requires 
ongoing physical therapy and occupational therapy but does not show that the enrollee requires an intense 
rehabilitation regimen in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1-L2 kyphoplasty (22514. 22515). 
 
You asked the Plan to pre-approve L1-L2 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial 
with multilevel disc disease in the spine. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
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 L1-L2 kyphoplasty. Our reviewer says 
that the enrollee does not meet coverage criteria. Our physician reviewer found there is no trial of a back brace. 
More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1-L2 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve L1-L2 kyphoplasty (22514. 22515).
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 live at home not getting the constant help needed 
in order to start walking. The Plan denied your request. The Plan says your records do not show that you need 
an intensive team for care. Services needed may be provided safely in a lower 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 the molded distal cushion (L5668), protective outer 
surface covering (L5962), and flex-walk system (L5981). 
 
You asked the Plan to pre-approve the molded distal cushion, protective outer surface covering, and flex-walk 
system. You say that the items are medically necessary. The Plan denied your request. The Plan says the items 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that overage is extended only if there is sufficient clinical 
documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 molded distal cushion, protective 
outer surface covering, and flex-walk system. Our reviewer says that the items are not medically necessary. 
Our physician reviewer found the requested gel liners have extra padding and the extra distal cushion would be 
a duplicate request and not medically necessary. The documentation does not support that the member has 
special needs for protection against unusually harsh environmental situations where it is necessary to protect 
the lower limb prosthesis beyond the level of protection that is afforded by a standard prosthetic cover. The treating medical physician provider documentation does not support that the member K3 ambulator given the 
use of her assistive devices.  
 
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 molded distal cushion, protective outer surface covering, and flex-walk 
system have not been met. Therefore, we decided that the Plan does not have to pre-approve the molded distal 
cushion (L5668), protective outer surface covering (L5962), and flex-walk system (L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460), and problem focused limited 
oral evaluation (D0140), and to pay more for the first intraoral periapical x-ray (D0220) provided on November 
3, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the dental services. You say that you were sent to an OON provider to receive 
these services. You also say that you would like the Plan to reimburse you at least partially for the services. 
The Plan denied your request. The Plan says pulp vitality tests are not a covered benefit. The Plan says that you 
have exceeded the limits set in the subscriber agreement for a problem focused limited oral evaluation. The 
Plan also says that you are responsible for any charged amount above the Plans cost-sharing amount when 
your services are received from an out-of-network provider.  
 
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, pulp vitality tests (D0460) are not 
among those covered under this benefit. The record shows your benefit for the problem focused limited oral 
evaluation (D0140) was exhausted on October 26, 2022. You have also been asked to pay the difference 
between the out-of-network providers charges and the Plans payment for the first intraoral periapical x-ray 
(D0220). This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay for the pulp vitality tests (D0460), and problem 
focused limited oral evaluation (D0140), and to pay more for the first intraoral periapical x-ray (D0220) 
provided on November 3, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Decipher Prostate assay.  
 
You asked the Plan to pre-approve the Decipher Prostate assay. You say that the Decipher Prostate assay is 
medically necessary. The Plan denied your request. The Plan says the Decipher Prostate assay does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that the Decipher Prostate assay is covered when the 
criteria listed in the Medicare rules section of this decision are 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 Decipher Prostate assay. Our 
reviewer says that the Decipher Prostate assay is not considered medically necessary. Our physician reviewer 
found that the Decipher Prostate assay is useful to predict the risk of clinical metastases in men that have 
undergone or will undergo definitive local treatment (surgery or radiation) and determine the need for 
additional treatment with androgen deprivation. In this case, the enrollee has confirmed metastasis to the pelvic 
lymph nodes and will need androgen deprivation in addition to local 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 Decipher Prostate assay have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Decipher Prostate assay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the requested power 
wheelchair and accessories are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that you are not at 
a high risk for skin breakdown. You do not use a catheter intermittently, have spasticity, or require an 
alternative means of managing the power drives. As the power wheelchair base is not medically necessary, the 
requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266), the removal of 
torus mandibularis (D7473), a bone replacement graft (D7953), deep sedation (D9222 and D9223), and the 
therapeutic drugs (D9612). 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are necessary 
so you can get your dentures. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the guided tissue regeneration, the removal of torus mandibularis, a bone 
replacement graft, deep sedation, and the therapeutic drugs are not covered by the Plan. 
 
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 the 
guided tissue regeneration (D4266), the removal of torus mandibularis (D7473), a bone replacement graft 
(D7953), deep sedation (D9222 and D9223), and the therapeutic drugs (D9612).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home or residence visit for the evaluation and 
management of an established patient (99349) provided on February 1, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The billed service, 99349, was 
denied because the diagnosis codes associated to it, G30.9 (Alzheimer's disease, unspecified) and F03.93 
(Unspecified dementia, unspecified severity, with mood disturbance), should not be reported together. Based 
on the ICD-10-CM Official Guidelines for Coding and Reporting: "An Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together, such as a congenital form versus an acquired form of the same 
condition." The billed service has been denied because it was reported with one or more diagnosis code pairs 
that are subject to an Excludes1 note. Therefore, we decided that the Plan does not have to pay for the home or residence visit for the evaluation and management of an established patient (99349) provided on February 1, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular implant/abutment supported removable 
denture for edentulous arch (D6111), placement of semi-precision attachments (D6192 x2), and placement of 
semi-precision abutments (D6191 x2) provided on October 4, 2022. 
 
  You asked the Plan to pay for the mandibular implant/abutment supported removable denture, placement of 
semi-precision attachments, and placement of semi-precision abutments. You say that you would like to be 
reimbursed for the dental charges for the post anchor implants, which is the final stage of the lower denture 
implant process. The Plan denied your request. The Plan says you do not have non-Medicare covered dental 
benefits with the Health Plan. The Plan also says that you are responsible for the full cost of the non-covered 
services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the mandibular implant/abutment 
supported removable denture for edentulous arch (D6111), placement of semi-precision attachments (D6192 
x2), and placement of semi-precision abutments (D6191 x2) provided on October 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special power wheelchair. 
 
You asked the Plan to pre-approve a special power wheelchair. You say that this item should be covered. The 
Plan denied your request. The Plan says equipment used in a skilled nursing facility cannot be 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.  
 
Records show that a special power wheelchair is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve a special power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyperbaric Oxygen (HBO) therapy (G0277, 99183). 
 
You asked the Plan to pre-approve HBO therapy. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bisphosphonate-
induced osteonecrosis of the jaw. He must have complete healing of the jaw before undergoing stem cell 
transplantation for multiple myeloma. The review has determined that the enrollee meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyperbaric Oxygen (HBO) therapy (G0277, 99183).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PuraPly AM. 
 
You asked the Plan to pre-approve PuraPly AM. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet coverage requirements. 
 
The Plan follows Medicare rules. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PuraPly AM. Our reviewer says that 
you do not meet coverage criteria. Our physician reviewer found the records do not indicate demonstrable 
improvement in healing with repeated applications of skin substitute in addition to comprehensive wound care. 
The review has determined that the records show that you have not had improvement or change in the size or 
depth of the wound in the past four weeks. It is not clear that the wound therapy with this skin substitute 
demonstrates indication that improvement is likely. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PuraPly AM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PuraPly AM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy. 
 You asked the Plan to pre-approve Hyperbaric Oxygen Therapy. You say that Hyperbaric Oxygen Therapy is 
medically necessary. The Plan denied your request. The Plan says the requested Hyperbaric Oxygen Therapy 
does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that Hyperbaric Oxygen Therapy is covered when the 
criteria listed in the Medicare rules section of this decision are 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 Hyperbaric Oxygen Therapy. Our 
reviewer says that the requested Hyperbaric Oxygen Therapy is not considered medically necessary in this 
case. Our physician reviewer found that the enrollee has Type 2 diabetes mellitus with foot ulcer, non-pressure 
chronic ulcer of right ankle with fat layer exposed, and non- pressure chronic ulcer of other parts of the right 
foot with fat layer exposed. The records sent do not show that the enrollee has completed standard wound 
therapy and that his vascular problems are properly assessed and corrected. The review has determined that the 
requested Hyperbaric Oxygen Therapy does not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyperbaric Oxygen Therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Hyperbaric Oxygen Therapy.