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

 
We decided that the Plan does not have to pre-approve unlisted procedure, dentoalveolar structures (41899). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
unlisted procedure, dentoalveolar structures (41899).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous lumbar intravertebral disc injection 
procedure (0627T). 
 
You asked the Plan to pre-approve percutaneous lumbar intravertebral disc injection procedure. You say that 
this is medically necessary. The Plan denied your request. The Plan says this is considered experimental/ 
investigational due to lack of literature establishing clinical efficacy, safety, or the applicability to clinical 
practice. 
 
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 percutaneous lumbar intravertebral disc 
injection procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found percutaneous disc injection and 
discectomy is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous lumbar intravertebral disc injection procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous lumbar intravertebral disc 
injection procedure (0627T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010 x 2) and sinus 
augmentations via a vertical approach (D7952 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain and require these 
procedures. The Plan denied your request. The Plan says these services are not covered benefits under your 
dental 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 
endosteal implants (D6010 x 2) and sinus augmentations via a vertical approach (D7952 x 2).
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 admission is medically necessary for you. The Plan 
denied your request. The Plan says your condition does not meet all the requirements for inpatient 
rehabilitation admission. The Plan says services may be provided 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical records 
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. It is not a 
reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on July 11, 2023. 
 
You asked the Plan to pay for a specialist office visit. You say that you called and called to try and get a list of 
in-network providers, but were unable to get anything in a timely manner. 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 a specialist office visit 
provided on July 11, 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for intensive 
multidisciplinary therapy provided by acute rehabilitation. The Plan is reaching out to the physician to discuss 
and approve the enrollee for 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The medical 
records 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. It is not a 
reasonable expectation that the 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: 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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about the enrollee's condition, they do not meet all of the requirements for IRF 
admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for peripheral vascular disease and lower extremity cellulitis. 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 the 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nasal/sinus endoscopy, surgical with ethmoidectomy; 
partial (anterior) (31254), and nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of 
tissue from maxillary sinus (31264). 
 
You asked the Plan to pre-approve nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior), and 
nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus. You 
say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that 
the enrollee has had a trial of medical management to treat the symptoms. 
 
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 nasal/sinus endoscopy, surgical with 
ethmoidectomy; partial (anterior), and nasal/sinus endoscopy, surgical, with maxillary antrostomy; with 
removal of tissue from maxillary sinus. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the 
enrollee has chronic sinusitis. The record provided does not document the failure of medical therapy. The 
record provided is insufficient to establish the medical necessity of the requested procedure at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior), and 
nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus have 
not been met. Therefore, we decided that the Plan does not have to pre-approve nasal/sinus endoscopy, surgical 
with ethmoidectomy; partial (anterior) (31254), and nasal/sinus endoscopy, surgical, with maxillary 
antrostomy; with removal of tissue from maxillary sinus (31264).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that the Life2000 System, which was 
prescribed will help the enrollee manage pulmonary exacerbations at home. The Plan denied your request. The 
Plan says the request cannot be approved at this time by Medicare or your health plan. You may meet criteria 
for a different type of breathing machine.   
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee had an elevated 
end-tidal carbon dioxide (ETCO2) but no arterial blood gas (ABG) to support hypercapnia. The enrollee does 
not have trail or documented use of CPAP or BiPAP, which would be a better starting point. Hence, no 
indication for home ventilator as documentation provided does not support the indication, as best practice at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this does not meet the standard of care because imaging reveals additional 
significant pathology that is unlikely to benefit from the procedure and is not approved. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
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 due to the enrollee's decline they are requiring 
rehabilitation services to regain their strength. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-discountable items and warranties provided on 
August 11, 2023. 
 
You asked the Plan to pay for the non-discountable items and warranties. You say that you are requesting 
reconsideration of the denial. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 have this service listed as a covered service. 
 
We looked at the file and the Plan's rules. Specifically, the service is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the non-discountable items and warranties have 
not been met. Therefore, we decided that the Plan does not have to pay for the non-discountable items and 
warranties provided on August 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on May 11, 2023. 
 
You asked the Plan to pay for the refraction. You say that you are requesting reconsideration of the denial. The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 covers these services when received during a routine eye examination. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was performed during a medical eye 
examination. Based on this information, we decided that the Plan's rules for coverage of the refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on May 11, 
2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve selective catheter placement, arterial system (36245, 36246, 
36247). 
 
You asked the Plan to pre-approve genicular artery embolization. You say that the enrollee has a high risk of 
bleeding complication. He needs to be operative and needs an embolization probe to not cause bleeding. The 
Plan denied your request. The Plan says that the request is not medically necessary because there is little 
evidence in the medical literature to suggest that this is an appropriate procedure to be used for the enrollee's 
knee arthritis. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular artery embolization. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a long history of bilateral knee pain and bone on bone 
degenerative joint disease of the knees. The enrollee has had prior gel procedures on both knees. The procedure 
is not considered experimental as there is a body of peer reviewed literature supporting it. Due to severe 
disability and the enrollee's age, the requested bilateral genicular artery embolization should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have been met. Therefore, we decided that the 
Plan has to pre-approve selective catheter placement, arterial system (36245, 36246, 36247).  
 
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 pay for the COVID-19 test provided on June 30, 2023. 
 
You asked the Plan to pay for the COVID-19 test. You say that you want to be reimbursed payment. The Plan 
denied your request. The Plan says the item is not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the COVID-19 
test provided on June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87150, 87481, 87641, 87653, 87798, and 
87801) provided on November 14, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
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 codes 87150, 87481, 87641, 87653, 87798, and 87801 are not supported in the medical 
record. Specifically, a panel was performed and there is a more appropriate singular code for the services. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the panel testing (87150, 87481, 87641, 87653, 
87798, and 87801) provided on November 14, 2022.