Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the complexity of the enrollee and 
prior hospitalization, the enrollee will continue to require acute care for a period of time before it will be safe 
enough to transition to a lower level of care. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for admission to the LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The elements 
of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the porcelain/ceramic dental crown (D2740) and the post and core in 
addition to a crown (D2952) provided on October 17, 2022. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that you have exhausted the allowable benefit 
for the dental items provided in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plans contract states that up to $1,250 is covered every year for 
non-Medicare covered preventive dental services and non-Medicare covered comprehensive dental services 
combined. The Plan has stated that you have exhausted the allowable benefit for the dental items provided in 
this case. However, the Plan has not provided substantive evidence that demonstrates the Plan previously 
issued payment in the amount of $1,250 for dental services provided in the 2022 calendar year. The Plan has 
not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to 
pay for the porcelain/ceramic dental crown (D2740) and the post and core in addition to a crown (D2952) 
provided on October 17, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is medically necessary. The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs are 
being met at current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but not yet stable for transfer at this time and 
requires additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. The enrollee does not require services at the LTACH that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) and a computed tomography 
(CT) Scan of the head. 
 
You asked the Plan to pre-approve the MRI and CT scans. You say that the services are medically necessary 
for the management of refractory essential tremor evaluation, and to determine the best course of treatment. 
The Plan denied your request. The Plan says that the testing is not medically necessary at this time.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs and CT scans are covered only when they 
are medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI and CT scans. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the enrollee has undergone 
evaluation for a magnetic resonance guided focused ultrasound for their tremor. Part of the diagnostic work-up 
for the procedure is to rule out intracranial processes. Performance of the MRI would be the most appropriate 
and sensitive manner to complete such imaging. A CT scan would show the skull density ratio and would be 
the optimal modality to perform this calculation. Both scans are found to be 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 MRI and CT scans have been met. Therefore, we decided that the Plan has 
to pre-approve a magnetic resonance imaging (MRI) and a computed tomography (CT) Scan of the head.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 0117U billed for date of service January 25, 2022. 
 
You asked the Plan to pay for the billed services. You say that this is a Medicare allowed code. The Plan 
denied your request. The Plan says that the code is non-covered for pharmacogenomic testing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Local Coverage Article, A58801, the Plan used in their decision to 
deny services is not binding in this case. This ruling does not have Medicare Part B jurisdiction for Kentucky, 
where the services were provided. The Plan has not offered any other rationale for denial. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request.  Therefore, we decided that the Plan has to pay for procedure code 0117U billed for date of 
service January 25, 2022.  
 
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 a Freedom Plie knee (L5828, L5848, L5845, L5856, 
L5850). 
 
You asked the Plan to pre-approve a Freedom Plie knee. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Coverage 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 a Freedom Plie knee. Our reviewer says 
that the enrollee does not need this item. Our physician reviewer found the medical documentation does not 
support that the enrollee requires a K3 microprocessor knee over a standard mechanical knee. 
 
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 Freedom Plie knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freedom Plie knee (L5828, L5848, L5845, L5856, L5850).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs medical management 
to return to their highest level of function. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary, and the enrollee's needs can be met in their current setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power wheelchair (E1220). 
 
You asked the Plan to pre-approve a heavy-duty power wheelchair. You say that a new chair was to be 
delivered but you never received it, and the chair that you have they do not make anymore. You also say that 
you have fallen out of your current chair, and need a new one. The Plan denied your request. The Plan says the 
records received from your primary care physician indicate you weighed 230 pounds on May 8, 2023. The Plan 
also says that since you weigh 230 pounds you do not meet the Medicare guidelines for a heavy-duty power 
wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty PWC is covered for a beneficiary 
weighing 285 to 450 pounds. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty power wheelchair have not been met. Specifically, the provided records show that 
your most recent documented weight is below the required weight limit of 285 to 450 pounds for a heavy-duty 
power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty power 
wheelchair (E1220).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesiafirst 15 minutes 
(D9222) and the deep sedation/general anesthesiaeach subsequent 15 minute increment (D9223 x 3) provided 
on January 3, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
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 services provided are not among 
those covered under this benefit.   
 
Therefore, we decided that the Plan does not have to pay for the deep sedation/general anesthesiafirst 15 
minutes (D9222) and the deep sedation/general anesthesiaeach subsequent 15 minute increment (D9223 x 3) 
provided on January 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets Medicare criteria for 
an LTACH admission and will benefit from these services that cannot be accomplished at a lower level of care. 
You would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
admission to the LTACH is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it would not be clinically advantageous.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you are 
asking for the denial to be reviewed and reprocessed for payment. The Plan denied your request. The Plan says 
these services are not a covered benefit.  
 
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 November 17, 2022. 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 with no 
transport provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous minimally invasive image guided 
endoscopic decompression (MILD/PILD) (22899). 
 
You asked the Plan to pre-approve the surgical service. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says there is no documentation showing the enrollee is part of a Medicare-
approve clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous image-guided lumbar 
decompression (PILD) for lumbar spinal stenosis (LSS) may only be covered under the context of a clinical 
trial.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical service have not been met. Therefore, we decided that the Plan does not have to pre-
approve percutaneous minimally invasive image guided endoscopic decompression (MILD/PILD) (22899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone 
replacement graft for ridge preservation (D7953) provided on June 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider should not be billing the Plan 
because you have paid for the services in full at the providers office already. 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 claim number E5360TX5700. Therefore, 
we decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone replacement 
graft for ridge preservation (D7953) provided on June 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Minuteman G3R Interspinous 
device to L3-L4 (22612). 
 
You asked the Plan to pre-approve implantation of the Minuteman G3R Interspinous device to L3-L4. You say 
that you want the Plan to approve this service. The Plan denied your request. The Plan says medical studies 
haven't proven this service/item is helpful. 
 
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 implantation of the Minuteman G3R 
Interspinous device to L3-L4. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found current evidence-based medical guidelines 
and peer-reviewed literature do not fully support the interspinous fusion device procedure over the gold 
standard of lumbar fusion. There is a lack of large-volume, long-term peer-reviewed outcome studies to 
support the use of this device for this enrollees medical condition. In addition, there are multiple alternate pain 
generators plausibly significantly contributing to the clinical condition that have not been fully documented as 
having been excluded and/or ruled out. No compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of the Minuteman G3R Interspinous device to L3- L4 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve implantation of the Minuteman 
G3R Interspinous device to L3-L4 (22612).
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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not have an acutely complex medical diagnosis and does 
not require supervision by a rehabilitation physician. The member does not meet all the required Medicare 
criteria for admission to an Inpatient Rehabilitation Facility. While the member will likely benefit from 
ongoing therapy to enhance her rehabilitation potential, there is no evidence that this cannot safely be done at 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64492 billed for date of service October 17, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the records support the necessity of the services. 
The Plan denied your request. The Plan says coverage criteria have not been met. 
 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 64492 is not supported in the medical record. Specifically, the records do not show a 
unique circumstance in which a third level needed to be provided on the same date as two other levels. Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 64492 billed for date of service 
October 17, 2022.