Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left total knee arthroplasty. 
 
You asked the Plan to pre-approve the left total knee arthroplasty. You say that you cannot complete physical 
therapy because you cannot walk. The Plan denied your request. The Plan says the total knee arthroplasty is not 
medically necessary. The Plan says there were no records of prior physical therapy participation. 
 
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 left total knee arthroplasty. Our 
reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are being treated for right hip pain; status post revision of total hip replacement; 
and left knee pain. The detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. You have failed modified activity, physical therapy, and medications. However, there is no indication that you have tried and failed injection 
therapy. Additionally, the previous reviews indicated the physical therapy trial was not fully corroborated in the 
documentation. 
 
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 left total knee arthroplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the left total knee arthroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says we have 
confirmed that  eleven one-way transportation trips have been exhausted so far this year. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve twelve 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve twelve additional routine transportation trips (A0120).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on December 6, 2021, to 
December 28, 2021. 
 You asked the Plan to pay for the home health services. You say that  the medical records support the services 
rendered were medically necessary.  The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found per Chapter 7 the 
enrollee has chronic stable condition without exacerbation. No skilled nursing needs, and no skilled nursing 
intervention was 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided on December 6, 2021, to December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a sacroiliac joint 
injection is 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee's physical exam 
shows only one positive sacroiliac joint maneuver and the other physical exam tests are noted to be negative. 
The LCD requires at least three positive fining with provocative maneuvers. Therefore, the request is not 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services reported with DRG 871 rendered 
from October 31, 2022, to November 9, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the review did not find sufficient 
documentation to clinically validate the diagnosis of J96.01 - acute respiratory failure with hypoxia. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with fever and chills following a prostate biopsy.  There were concerns that the 
patient had early bacteremia/sepsis from the biopsy, versus a complicated urinary tract infection (UTI), versus 
aspiration from either the procedure or a known Zenkers diverticulum. The enrollee continued to have a fever 
and cough throughout his hospital stay. Blood cultures, a urine culture and respiratory panels were all 
negative. Ultimately, the enrollees symptoms were attributed to aspiration/pneumonitis. There is no evidence 
that the enrollee had sepsis or respiratory failure. As such, the billing of A41.9, J96.01 and R65.20 is not 
supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services reported with DRG 871 rendered from October 31, 2022, to November 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says a SNF admission is not medically necessary.  
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Enzalatumide (Xtandi) (C9399). 
 
You asked the Plan to pre-approve the drug. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says that XTandi is self-administered so is not covered by Medicare Part B. 
 
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 drug. Our physician reviewer found 
Enzalatumide (Xtandi) is an oral medication that is Food and Drug Administration (FDA) approved for the 
treatment of metastatic castration-sensitive prostate cancer. It is a standard of care in high-risk disease such as 
this enrollee. The service is reasonable and medically 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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Enzalatumide (Xtandi) (C9399).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic mattress. 
 
You asked the Plan to pre-approve an orthopedic mattress. You say that your current mattress is too soft and 
your doctor recommended an orthopedic mattress.  The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an orthopedic mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye refraction and contact lens fitting. 
 
You asked the Plan to pre-approve an eye refraction and contact lens fitting. You say that the requested 
services are medically necessary due to a history of corneal transplant due to traumatic cataracts in the past. 
The Plan denied your request. The Plan says the 2023 National Physicians Fee Schedule lists procedure codes 
92310 and 92015 with status indicators of N which represents an item or service that is not covered by 
Medicare.  
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file, the Plans rules and the Medicare rules. Medicare does not pay for procedures performed 
in the course of any eye exam to determine the refractive state of the eyes. The Plan medical vision benefit does 
not include a routine eye exam (refraction) for the purpose of prescribing glasses. The Plan vision benefit does 
not provided coverage for contact lens fitting. Therefore, we decided that the Plan does not have to pre-approve 
an eye refraction and contact lens fitting.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final 
restoration) (D3310). 
 
You asked the Plan to pre-approve the endodontic therapy. You say that if you work with the provider you 
want to see this would be better for you. You also say that you would like to get approval to continue going to 
this provider to continue getting the work done for your toothache. The Plan denied your request. The Plan says 
dental services from an out-of-network provider are not covered by your supplemental benefits. There are in-
network providers within your service area who can accommodate you in a timely manner. 
 
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. 
 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested service is not covered under this benefit when received from an 
out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, 
anterior tooth (excluding final restoration) (D3310).
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 health is in danger and needs a lot of 
medical care and intense physical and occupational therapy. 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 enrollees 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 IRF admission and services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for colonoscopy, flexible; with biopsy, single or multiple rendered on 
January 18, 2023. 
 
You asked the Plan to pay for the services. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says that Current Procedural Terminology (CPT) code 45380 remains not 
supported. 
 
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, the CPT Code Manual definition of 
code 45380 is "Colonoscopy, flexible; with biopsy, single or multiple." 
 
We asked our coder 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 services at issue in 
this case were supported by the medical records. Our reviewer found that the records support the use of CPT 
45380. The colonoscopy was performed, and later in the day, due to the results, an exploratory laparotomy was 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
colonoscopy, flexible; with biopsy, single or multiple rendered on January 18, 2023.  
 
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 pay for skilled nursing facility (SNF) services rendered from 
February 23, 2021, to February 28, 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 coding in this case is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 services at issue 
in this case were not supported by the medical records. Our reviewer found that based on the limited 
documentation provided, the coding in this case is not supported. There is no evidence that the enrollee had an 
infectious disease or that the enrollee was medically required to be in isolation. 
 
We looked at this coder'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 skilled nursing facility (SNF) services rendered from February 23, 2021, to February 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator (E0760). 
 
You asked the Plan to pre-approve the bone growth stimulator. You say that this device is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a bone growth stimulator is covered for non-
union of long bone fractures. Effective September 15, 1980, non-union of long bone fractures is considered to 
exist only after 6 or more months have elapsed without healing of the fracture. 
 
We looked at the file and Medicare rules. Six or more months have not passed since the surgical procedure. 
Based on this information, we decided that Medicare rules for coverage of the bone growth stimulator have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator (E0760).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Intravenous Therapeutic Infusions and a maintenance/refill 
of infusion pump provided on January 5, 2023. 
 
You asked the Plan to pay for Intravenous Therapeutic Infusions and a maintenance/refill of infusion pump. 
You say that the services were medically necessary. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.  
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for Intravenous Therapeutic Infusions and a maintenance/refill of 
infusion pump provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on May 22, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had a second dentist appointment, and you 
did not know that another set of x-rays would be at cost. 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for the panoramic radiographic images (D0330) on February 23, 2021; therefore, your 
benefit for the requested item or service was exhausted on the date of service of February 23, 2021. Therefore, 
we decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (D3330) for tooth #19. 
 
You asked the Plan to pre-approve the root canal. You say that this procedure is medically necessary. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 29, 2023. Therefore, 
we decided that the Plan does not have to pre-approve a root canal (D3330) for tooth #19.