Persius/hicric huggingface dataset:
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 IRF services are necessary to manage the enrollee's 
current medical needs while receiving rehabilitation to optimize their physical function. The Plan denied your 
request. The Plan says based on the records received, IRF services are not supported.  
 
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 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the basivertebral nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the basivertebral nerve radiofrequency ablation. You say that the enrollee 
has tried and failed conservative treatment without relief.  The Plan denied your request. The Plan says  the 
basivertebral nerve radiofrequency ablation 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 basivertebral nerve radiofrequency 
ablation. Our reviewer says that the basivertebral nerve radiofrequency ablation is not medically necessary. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes 
without facet degenerative joint disease or foraminal stenosis. Also, the cause of the back pain is not clear. 
Therefore, the Medicare criteria has not been met. 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 basivertebral nerve radiofrequency ablation have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the basivertebral nerve radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig (A9282). 
 
You asked the Plan to pay for the wig. You say that the item should be covered. The Plan denied your request. 
The Plan says this is not a covered item. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig (A9282).
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 that no one is helping the enrollee regain their 
mobility. The Plan denied your request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service March 9, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support medical necessity. 
The Plan denied your request. The Plan says the test should be billed under a single code. 
 
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 looked at the file and the rules. The panel testing was not billed with single code as required. The records 
do not show that the testing was ordered due to a gene-drug interaction. Medications should be provided based 
on the presence of a diagnosis and should be adjusted based on a patient's response to the medication. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab testing billed for date of service March 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LinQ Sacroiliac (SI) Joint Stabilization Surgery. 
 
You asked the Plan to pre-approve the LinQ Sacroiliac (SI) Joint Stabilization Surgery. You say that the 
enrollee has tried and failed multiple conservative measures without relief. You say the enrollee has undergone 
multiple SI joint injections and the SI joint is the primary pain generator. The Plan denied your request. The 
Plan says the LinQ SI Joint Stabilization Surgery is not medically necessary, and the Plan considers this 
surgery experimental. 
 
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 LinQ Sacroiliac (SI) Joint 
Stabilization Surgery. Our reviewer says that the requested item is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee was being treated for sprain of the sacroiliac joint. The detailed documentation is not evident regarding imaging or radiographic evidence 
supporting a sacroiliitis pathology. Multiple other plausible pain generators including at the lumbosacral spine 
are evident. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. Therefore, the requested LinQ sacroiliac (SI) 
joint stabilization surgery 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 LinQ Sacroiliac (SI) Joint Stabilization Surgery have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the LinQ Sacroiliac (SI) Joint Stabilization 
Surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  oral hygiene instructions (D1330), prophylaxis  adult 
(D1110) and topical application of fluoride varnish (D1206) provided on May 2, 2023. 
 
You asked the Plan to pay for  these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
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 $10 
copayment for dental services.  
 
 You have been asked to pay $10 copayment for prophylaxis  adult, 50% coinsurance for topical application of 
fluoride varnish and the oral hygiene instructions are not a covered benefit. These items/services fall within the 
dental services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to pay for  oral hygiene instructions (D1330), 
prophylaxis  adult (D1110) and topical application of fluoride varnish (D1206) provided on May 2, 2023.
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for admission to the 
LTACH have not been met.  
 
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 with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer to a lower level of care. 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 would not be 
clinically advantageous at this time and completion of treatment at the current facility is recommended.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended sleep study (95810). 
 
You asked the Plan to pre-approve an attended sleep study. You say that this service is medically necessary. 
You also say that the denial of this service is not justified, considering the enrollee's symptoms and medical 
history, which strongly indicate the need for a comprehensive sleep study. The Plan denied your request. The 
Plan says the documentation submitted does not indicate any of the Plan's indications for coverage. 
 
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 an attended sleep study. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is experiencing sleep disorder symptoms, but more data is required in the 
documentation to support a sleep study. It is difficult to ascertain from current data the need for formal sleep 
study or at minimum, sleep questionnaires, sleep hygiene, and sleep diary for further data to determine need for 
further testing. Our reviewer found that a determination cannot be made based on the current documentation or 
data points. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an attended sleep study (95810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) purchased on February 17, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that you were unaware that you needed to 
go through the Plan hearing for their services. The Plan denied your request. The Plan says items are to be 
supplied by the Plan hearing. 
 
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 they are obtained by an in-network provider.  
 
 
  We looked at the file and the Plan's rules. The Plan rules say that hearing aids purchased outside of the Plan 
hearing are not covered. The record shows the hearing aids were purchased out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of hearing aids (V5298) have not been met. 
Therefore, we decided that the Plan does not have to reimburse for hearing aids (V5298) purchased on 
February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clinical crown lengthening-hard tissue (D4249) provided on 
September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 clinical crown lengthening-hard tissue (D4249) provided on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on April 17, 
2023. 
 
You asked the Plan to pay for oral hygiene instructions (D1330). You say that you do not know why the Plan 
denied your service. The Plan denied your request. The Plan says according to your dental care plan 
information guide, procedures that are not listed on the patient charge schedule are not covered. The Plan also 
says that any services performed that are not covered are your responsibility. 
 
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 oral 
hygiene instructions (D1330) provided on April 17, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you had back surgery and learned how to walk again 
with the use of a walker. You say you have steps into your home and have not practiced steps within therapy.  
The Plan denied your request. The Plan says the request for SNF coverage does not meet Medicare criteria.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. You 
do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report (comprehensive 
hereditary pharmacogenomic testing) and the Hereditary Genetic Cardiac Test panel  
 
You asked the Plan to pay for the GeneDose Genetic Response Report (comprehensive hereditary 
pharmacogenomic testing) and the Hereditary Genetic Cardiac Test panel. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when the criteria listed in the 
Medicare Rules section is 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 pay for the GeneDose Genetic Response Report 
(comprehensive hereditary pharmacogenomic testing) and the Hereditary Genetic Cardiac Test panel. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there was no 
documentation of newly planned treatment and how the testing would impact management. The enrollee was 
asymptomatic from a cardiac standpoint. The testing appears to be screening.  
 
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 GeneDose Genetic Response Report (comprehensive hereditary 
pharmacogenomic testing) and the Hereditary Genetic Cardiac Test panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the GeneDose Genetic Response Report (comprehensive 
hereditary pharmacogenomic testing) and the Hereditary Genetic Cardiac Test panel
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day reader. 
 
You asked the Plan to pre-approve Freestyle Libre 14-day reader. You say that the Freestyle Libre 14-day 
reader is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre 14-day reader. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found that the record indicates 
that you have diabetes. However, the record provided does not indicate that you are being treated with insulin 
or have problematic hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are 
not satisfied; therefore, the requested service is not recommended. 
 
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 Freestyle Libre 14-day reader have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Freestyle Libre 14-day reader.