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

 
We decided that the Plan does not have to pre-approve a C4-5, C6-7 total disk arthroplasty with C5-6 anterior 
cervical discectomy and fusion (ACDF). 
 
You asked the Plan to pre-approve the total disk arthroplasty and ACDF. You say that this surgery was 
approved to be performed by another doctor. You say that that doctor's approach would result in the loss of 
your neck mobility which you did not want. You also say that this why you sought the surgery from another 
doctor who said they could preserve your neck movement. The Plan denied your request. The Plan says these 
procedures are considered hybrid techniques and are unproven and 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 total disk arthroplasty and ACDF. 
Our reviewer says that the requested total disk arthroplasty and ACDF are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested hybrid procedure is considered 
experimental. The reviewer found that the Food and Drug Administration  (FDA) has not approved total disc 
replacement at 2 levels when combined with fusion. Therefore, the reviewer found that the requested total disk 
arthroplasty and ACDF are not medically reasonable or 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 total disk arthroplasty and ACDF have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a C4-5, C6-7 total disk arthroplasty with C5-6 anterior cervical 
discectomy and fusion (ACDF).
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 admission to an IRF is medically necessary, and you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
enrollee does not meet 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 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. While the enrollee may have a need for physical therapy and/or occupational 
therapy, the documentation does not show the enrollee requires or would tolerate an intensive rehabilitation 
regimen.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466) . 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item 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.  
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 home mechanical ventilator. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee could be 
treated with a BiPAP machine with average volume assured pressure support (AVAPS) capability and failure 
of such a device has not been documented. 
 
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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466) .
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this device is medically necessary 
for the enrollee. The Plan denied your request. The Plan says this device is considered investigational. 
 
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 CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in the enrollees 
clinical management.  
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on April 28, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in a 
nursing home. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on April 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve SNF services. 
 
You asked the Plan pre-approve SNF services. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the enrollee has reached the 100-day benefit limit for this admission. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 104 days of SNF care during the benefit period from March 17, 2022, 
to January 27, 2023. The Plan has covered more than 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 09, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on February 09, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization (93458). 
 
You asked the Plan to pre-approve the heart catheterization. You say that your doctor is requesting this 
procedure, so it needs to be done. The Plan denied your request. The Plan says the procedure is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that left heart catheterization is only covered for 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 the heart catheterization. Our reviewer 
says that the request for left heart catheterization is not medically necessary. Our physician reviewer found the 
provided documentation indicates the enrollee had a normal stress test. The reviewer found that the 
documentation does not give a reason for this invasive imaging study. Therefore, the reviewer found that the 
heart catheterization 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 heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization (93458).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital hearing aid (V5257), and an ear mold (V5264) 
provided on December 2, 2022. 
 
You asked the Plan to pay for a digital hearing aid (V5257), and an ear mold (V5264). You say that you are 
appealing with no supporting records. The Plan denied your request. The Plan says hearing aids must be 
purchased through the Plan hearing network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you obtain prior authorization from the Plan hearing network. The Plan rules also says 
that hearing aids purchased outside of the Plan hearing network are not covered.  
 
  We looked at the file and the Plan's rules. The Plan rules say that you must obtain prior authorization from the 
Plan vendor network. The Plan rules also say that hearing aids purchased outside of the Plan hearing network 
are not covered. The record shows the hearing aids were purchased outside of the Plan network and no prior 
authorization was obtained. Based on this information, we decided that the Plan's rules for coverage of a digital 
hearing aid (V5257), and an ear mold (V5264)  have not been met. Therefore, we decided that the Plan does 
not have to pay for a digital hearing aid (V5257), and an ear mold (V5264) provided on December 2, 2022.
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 will benefit from a 
regimented mobility schedule that cannot be facilitated in the current setting or at a lower level of care. The 
Plan denied your request. The Plan says an LTACH admission 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a precision attachment (D5862) and a complete 
mandibular overdenture (D5865). 
 
You asked the Plan to pre-approve a precision attachment (D5862) and a complete mandibular overdenture 
(D5865). You say that you have had pain and inflammation. You also say that you really need your denture. 
The Plan denied your request. The Plan says the service that was sent in by your dentist is not covered on your 
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 a 
precision attachment (D5862) and a complete mandibular overdenture (D5865).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the scanning computerized ophthalmic diagnostic 
imaging (92133). We decided that the Plan does not have to waive the copayment for the medical eye exam 
(92014) or pay in full for the scanning computerized ophthalmic diagnostic imaging (92133).  
 
You asked the Plan to waive the cost shares for the medical eye exam (92014) and scanning computerized 
ophthalmic diagnostic imaging (92133) provided on April 7, 2023. You say that no different tests were done 
during this examination, and you feel that this should have been considered an annual exam. The Plan says that 
this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the coinsurance for the scanning computerized ophthalmic 
diagnostic imaging (92133).  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay 15% coinsurance for all other outpatient diagnostic tests 
provided in-network.  
 
The Plan says you must pay $5.52 for the diagnostic imaging. Based on the Plan contract, however, you cannot 
be asked to pay more than 15% coinsurance for outpatient diagnostic tests provided in-network. Therefore, we 
decided that the Plan has to reduce the coinsurance for the scanning computerized ophthalmic diagnostic 
imaging (92133).  
 
We also decided that the Plan does not have to waive the copayment for the medical eye exam (92014) or 
pay in full for the scanning computerized ophthalmic diagnostic imaging (92133). 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for the medical eye exam (92014), and you must pay 15% coinsurance for the scanning 
computerized ophthalmic diagnostic imaging (92133). Therefore, we decided that the Plan does not have to 
waive the copayment for the medical eye exam (92014) or pay in full for the scanning computerized 
ophthalmic diagnostic imaging (92133). 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D7956), custom fabricated 
abutment (D6057), and implant supported porcelain/ceramic (D6065). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says dental services from an out-of-network provider are not covered by your 
supplemental benefits.  
 
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 items or services are 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 guided tissue regeneration (D7956), custom fabricated abutment (D6057), and implant supported porcelain/ceramic 
(D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on March 16, 2023. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial because you were 
told everything was going to be covered. The Plan denied your request. The Plan says this service is not 
covered under your 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. Core buildup, including any 
pins when required (D2950) is not covered under the Plans dental benefit. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2950 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core buildup, 
including any pins when required (D2950) provided on March 16, 2023.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for an infection of an amputation stump and had an above the knee amputation. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting and the refraction provided on 
February 9, 2023. 
 
You asked the Plan to pay for the contact lens fitting and the refraction. You say that the scleral lens is 
medically necessary, and not cosmetic. You say you still need to wear corrective eyeglasses over the scleral 
lens. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover contact lenses and refractions are covered when provided during a routine 
eye exam with a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the services were provided by an out-of-network 
provider. Also, the contact lenses are not listed as a covered benefit. The refraction was provided during an eye 
exam that was medical in nature. Based on this information, we decided that the Plan's rules for coverage of the 
contact lens fitting and the refraction have not been met. Therefore, we decided that the Plan does not have to 
pay for the contact lens fitting and the refraction provided on February 9, 2023.