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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's care needs. The Plan denied your request. The Plan says the records do not show that the enrollee 
needs treatments that can only be given in a hospital setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. 
 
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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for PT services. 
 
You asked the Plan to pay for PT services. You say that your physical therapy visits should be covered in full 
after the $35 copayment. The Plan denied your request. The Plan says that the benefit maximum has been 
reached. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to provide documentation showing that a maximum benefit had 
been reached or any other rationale to support a denial of payment. Therefore, we decided that the Plan has to 
pay for PT services.  
 
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 the implant supported to crown (D6065) for tooth #11 
and custom fabricated abutment (D6057) for tooth #11. 
 
You asked the Plan to pre-approve the dental services. You say that the dental procedures are necessary for 
your improvement. The Plan denied your request. The Plan says your benefit for the requested items or services 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan approved custom fabricated abutments (D6057) for tooth #5 and #6, implant supported to 
crown (D6065) for tooth #5 and #6 and pontics (D6245) for tooth #7, #8, #9, and #10 on June 8, 2023; 
therefore, your benefit for the requested items or services was exhausted on the date of approval of June 8, 
2023. Therefore, we decided that the Plan does not have to pre-approve the implant supported to crown 
(D6065) for tooth #11 and custom fabricated abutment (D6057) for tooth #11.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would have a maximized 
benefit from a five to one nurse to patient ratio for more individualized care needs versus at a lower level of 
care. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for care in an 
LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 Our physician reviewer found the enrollee requires additional acute care services that can safely be provided at 
the current facility until more stable and appropriate for 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay at the psychiatric inpatient 
hospitalization level of care. 
 
 
 
 You asked the Plan to pre-approve a continued stay at the psychiatric inpatient hospitalization level of care. 
You say that the enrollee still displays a high level of depression, and needs medications. You also say that the 
enrollee is scared to return home. The Plan denied your request. The Plan says this request does not meet 
Medicare guidelines because the records do not show that the enrollee meets the criteria for active inpatient 
psychiatric care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued stay at the psychiatric 
inpatient hospitalization level of care. Our reviewer says that the enrollee does not meet the Medicare criteria 
for continued inpatient psychiatric care. Our physician reviewer found it is not expected this enrollee will 
improve in a reasonable period of time as they are not showing any dangerousness to self or others, auditory or 
visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. Our 
reviewer also found that it does not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than 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 a continued stay at the psychiatric inpatient hospitalization level of care have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continued stay at the 
psychiatric inpatient hospitalization level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee has a ventilator already. The Plan 
denied your request. The Plan says the documentation does not support that the use of a bilevel positive airway 
pressure (BiPAP) device would not meet the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
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 physical and occupational therapy 
to ensure that they are able to regain their strength and mobility to function independently. 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: 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 services are medically necessary for you to 
receive the level of care needed. The Plan denied your request. The Plan says your records do not show that 
you need an intensive team for your 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 you do 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastroesophageal reflux test (91035) and esophageal 
balloon distension study (91040). 
 
You asked the Plan to pre-approve a gastroesophageal reflux test and esophageal balloon distension study. You 
say that the doctor would like to perform an Endoscopy with biopsy, Potential of Hydrogen testing, and 
motility testing using an endoscopic functional luminal imaging probe (EndoFLIP) to see if the enrollee needs 
to stay on proton pump inhibitors. The Plan denied your request. The Plan says this request cannot be approved 
because the enrollee does not have gastroesophageal reflux disease (GERD) symptoms (heartburn, 
regurgitation) after their surgery. 
 
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 gastroesophageal reflux test and 
esophageal balloon distension study. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found at issue for this review however 
is not the medical appropriateness of Peroral endoscopic myotomy (POEM) in management of the enrollee's 
jackhammer esophagus, but rather the medical necessity of routine post-operative testing by EndoFLIP and 
Potential of Hydrogen (pH) monitoring in an enrollee without significant GERD symptoms who has per 
provided records been "doing well" on proton-pump inhibitor (PPI) therapy. Our reviewer also found that in the 
absence status post POEM of recurrent dysphagia or significant symptoms of gastroesophageal reflux, the 
medical necessity is not supported for all requested testing as is under this review. 
 
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 gastroesophageal reflux test and esophageal balloon distension study have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a gastroesophageal reflux test 
(91035) and esophageal balloon distension study (91040).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Iovera procedure. 
 
You asked the Plan to pre-approve the Iovera procedure. You say that you are scheduled for a total knee 
replacement, and the procedure was recommended to be done prior to the surgery to help deaden the nerves so 
the surgery is not so painful. The Plan denied your request. The Plan says the Iovera procedure is considered 
investigational and not a covered benefit.  
 
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 Iovera procedure. Our reviewer says 
that a Iovera procedure is not medically necessary. Our physician reviewer found that you are being treated for 
unilateral primary osteoarthritis of the left knee. The exam of the right need reveled patellar tenderness and 
crepitus. While there is medial and lateral joint line tenderness, there is limited literature that shows this request 
to be an effective or safe treatment for the noted pathology. Also, there is no indication to support the use of the 
Iovera treatment for post operative pain management following total knee arthroplasty as safe and effective. 
Additionally, there is no indication that standard post operative pain management would be insufficient for you. 
Therefore, the requested Iovera 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 a lovera procedure. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Iovera procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (0012M) provided on January 10, 2023 . 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this test is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has re-affirmed non-coverage for 
procedure codes 0013M and 0012M for CxBladder testing. 
 
We looked at the file and Medicare rules. This test is not covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we 
decided that the Plan does not have to pay for lab testing (0012M) provided on January 10, 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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) for tooth #11. 
 
You asked the Plan to pre-approve the dental service. You say that it is medically necessary that the enrollee 
get a crown and core buildup for their tooth. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the core buildup is not covered by the Plan. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
core buildup (D2950) for tooth #11.
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 services are medically necessary for the 
enrollee's care needs. The Plan denied your request. The Plan says ongoing skilled care can be provided in an 
alternate setting.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nucynta. 
 
You asked the Plan to pre-approve Nucynta. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nucynta.  Benefits for Nucynta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD or the MILD procedure). 
 You asked the Plan to pre-approve MILD procedure. You say that the enrollee is eligible for coverage and will 
be enrolled through Coverage with Evidence Development (CED) under NCT03072927. The Plan denied your 
request. The Plan says the records do not show that the enrollee will be able to meet the criteria for inclusion in 
the trial. 
 
The Plan follows Medicare rules. Medicare rules state that the MILD procedure is only covered for enrollees 
who meet criteria for inclusion in a qualifying CED study. 
 
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 MILD procedure. Our reviewer says 
that the enrollee does not meet criteria for the MILD procedure. Our physician reviewer found the enrollee 
does not have a diagnosis of lumbar spinal stenosis with neurogenic claudication. The date of the enrollee's 
previous laminectomy is not clearly documented. Moreover, the enrollee is noted to have had a previous MILD 
procedure without clear documentation of the date or location of this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. As the enrollee does not meet criteria for 
inclusion in the proposed NCT03072927, this procedure would not be covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of MILD procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD or the MILD procedure).