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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services as he was sent to a 
skilled nursing facility before, and they were not equipped to care for his medical needs. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for an 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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
requires treatment by multiple therapies, including physical therapy and occupational therapy, but this can be 
provided in a lower level of care. The documentation shows that there is a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from an intensive rehabilitation program provided in an 
IRF, but the services required can be provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure. 
 
You asked the Plan to pre-approve the VivAer procedure. You say that the VivAer procedure is medically 
necessary. The Plan denied your request. The Plan says under the Medicare guidelines the criteria for 
reasonable and necessary are not met as this device has not been shown to be safe and effective for treatment of 
your condition. Further, the documentation does not support that you meet the indications for this procedure 
and are free of contraindications for this procedure. You were noted to have deviated nasal septum, which your 
doctor stated may require surgical intervention for definitive treatment. 
 
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 VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has nasal obstruction and obstructive sleep apnea.  
There is insufficient literature to support the safety and efficacy of the requested service for the enrollee's 
specific conditions. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria 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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a meniscetomy including cartilage removal. 
 
You asked the Plan to pre-approve a meniscetomy including cartilage removal. You say that the enrollee would 
benefit from this procedure. The Plan denied your request. The Plan says the enrollee has not tried conservative 
methods.  
 
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 a meniscetomy including cartilage 
removal. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found detailed documentation regarding a trial and failure of 
recent, reasonable, comprehensive, less invasive conservative care measures is not evident. There are limited 
large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 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 a meniscetomy including cartilage removal have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a meniscetomy including cartilage removal.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RFA. 
 
You asked the Plan to pre-approve the RFA. You say that your severe knee pain is causing issues with your hip 
and gait. The Plan denied your request. The Plan says the request 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 RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 
 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve RFA.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the out-of-network dental services provided on May 24, 
2023. 
 
You asked the Plan to pay for the out-of-network dental services. You say that the representative from the Plan 
told you that your policy would pay your provider. You say the Plan has paid other claims in the past. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and 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. 
 
 
 The record shows you received the requested 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 pay for the out-of-network dental services provided on May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0862) and components. 
 
You asked the Plan to pre-approve Group 3 power wheelchair K0862. You say that this is the proper 
equipment. The Plan denied your request. The Plan says the enrollee does not have a medical need for the 
multiple power options. 
 
The Plan follows Medicare rules. Medicare rules state that a Group 3 power wheelchair with multiple power 
options may be covered if certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Group 3 power wheelchair K0862. Our 
reviewer says that the enrollee does not meet criteria for this wheelchair. Our physician reviewer found the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity, or require an 
alternative means of managing power drive. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Group 3 power wheelchair K0862 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0862) 
and components.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services. You also say the facility will 
not discharge you because you live alone. The Plan denied your request. The Plan says you do not meet the 
criteria for an 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 your nursing, medical, and rehabilitation needs, does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. There 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. 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 pre-approve an endosteal implant (D6010) for tooth #20, bone 
replacement graft for ridge preservation (D7953), a fixed partial denture sectioning (D9120), an anesthesia 
(D9222/D9223), and second stage implant surgery (D6011) for tooth #19, #20, and #22. 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental work. The Plan denied 
your request. The Plan says these services have been processed correctly. 
 
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 D6010 was exhausted with the approval of D6010 for teeth #19 and #22. D7953, 
D9120, D9222 or D9223 are not covered dental benefits. Therefore, we decided that the Plan does not have to pre-approve an endosteal implant (D6010) for tooth #20, bone replacement graft for ridge preservation 
(D7953), a fixed partial denture sectioning (D9120), an anesthesia (D9222/D9223), and second stage implant 
surgery (D6011) for tooth #19, #20, and #22.
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 left heart catheterization. You say that this service is medically necessary. 
The Plan denied your request. The Plan says the enrollee's records do not show that it is medically reasonable 
to pursue cardiac catheterization at this time in the work up of the enrollees problems, without other less 
invasive cardiac testing and evaluation first. 
 
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 left heart catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee had a recent negative radionuclide stress test. Guidelines do not 
support a need for invasive cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be considered medically appropriate and necessary in this enrollee's 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 left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization (93458).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service February 24, 2023. 
 
You asked the Plan to pay for code 99285. You say that this claim was correctly coded. The Plan denied your 
request. The Plan says code 99285 is not supported by the medical record. The records don't support a high 
level of medical decision making. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical records. Our reviewer found the medical documentation provided does not support 
this level of coding by complexity of the medical decision making involved. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service February 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left atrial appendage closure (LAAC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that LAAC is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of atrial 
fibrillation with elevated risk of thromboembolic stroke due to atrial fibrillation and elevated congestive heart 
failure, hypertension, age, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age, 
sex category (CHADS2VASC) score. Gastrointestinal (GI) bleeding has reportedly occurred due to a gastric 
ulcer. While there is reference to consideration of the LAAC, there is no documentation of performance of an 
evidence-based shared decision-making interaction on anticoagulation. As such, guidelines would not support 
implantation of a LAAC in this setting. LAAC placement is not reasonable or medically necessary in the 
enrollee's 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left atrial appendage closure (LAAC).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(BVN) (Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are continuously experiencing 
pain. You say that you cannot stand or walk for extended periods of time. You say that your back in broken. 
You also say that you cannot function without pain medications to complete activities of daily living (ADLs). The Plan denied your request. The Plan says the records do not suggest the BVN is the primary cause of your 
pain. 
 
The Plan follows Medicare rules. Medicare rules say that thermal destruction of the intraosseous basivertebral 
nerve (BVN) will be considered medically reasonable and necessary for the treatment of chronic low back pain 
(cLBP) in patients who show evidence of Type 1 or Type 2 Modic changes on magnetic resonance imaging 
(MRI). 
 
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 Intracept procedure is not medically necessary. Our physician reviewer found there is no 
magnetic resonance imaging (MRI) showing only Modic changes without facet degenerative joint disease. The 
reviewer found that there is not a clear cause for the enrollee's pain. Therefore, the reviewer found that the 
requested Intracept procedure is 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (BVN) (Intracept 
procedure) (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210) for tooth #31 provided on 
August 7, 2023. 
 
You asked the Plan to pay for the surgical extraction. You say that you were told that oral surgery would be 
covered this year. The Plan denied your request. The Plan says this is not a covered service 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. 
 
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 pay for a surgical 
extraction (D7210) for tooth #31 provided on August 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee was on a combination of Alimta 
and Keytruda, but the Alimta was causing significant side effects. It is reasonable to try Keytruda and assess 
the response in three months. The Plan denied your request. The Plan says the requested treatment order of 
Keytruda is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  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 medication. Our reviewer says that 
the requested use of Keytruda is not FDA approved for the enrollees diagnosis. Our physician reviewer found 
that the use of Keytruda is also not supported by one of the major drug compendia or by clinical research. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant services (D6010, D6011) provided on January 
23, 2023. 
 
You asked the Plan to pay for the implant services. You say that this implant is not cosmetic. The Plan denied 
your request. The Plan says this implant service is not a covered benefit 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. 
 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 pay for the 
implant services (D6010, D6011) provided on January 23, 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 LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for a LTACH admission. 
 
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 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 does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires, that are not available at 
the health care setting being offered by the Plan. Given there are offered alternatives, LTACH admission is not 
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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.