Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) with single power 
option and accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that you have had your wheelchair for 
more than 5 years and this is medically necessary. The Plan denied your request. The Plan says you do not 
meet criteria for the single power option so do not need the base wheelchair. 
 
The Plan follows Medicare rules. Medicare rules state that a Group 3 power wheelchair with single power 
option (such as K0856) is only 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. Our 
reviewer says that you do not meet criteria for the requested Group 3 power wheelchair. Our physician 
reviewer found you are functionally non-ambulatory and cannot use a cane or walker for mobility. You cannot 
functionally propel a manual wheelchair due to upper extremity weakness and shoulder pain. You cannot 
operate a power scooter due to impaired sitting balance and the accessibility of her living facility. You require a 
power wheelchair for mobility and accomplishing her daily activities. However, the clinical documentation is 
insufficient as to why a lower-level power wheelchair would not suffice for your needs versus a Group 3 power 
wheelchair. You are independent with transfers and can stand and while you may require power tilt, it is not 
clear why you require the advanced seating and positioning requirements necessitated by a Group 3 power 
wheelchair. You are not noted to have an advanced neurological disease, such as multiple sclerosis or spinal 
cord injury. Therefore, the Group 3 power wheelchair with power tilt and power elevating leg rests 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 Group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair (K0856) with single power option and 
accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Coflex interlaminar stabilization device. 
 
You asked the Plan to pre-approve Coflex. You say that the enrollee is a great candidate for Coflex. The Plan 
denied your request. The Plan says this procedure is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Coflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Coflex device is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Coflex have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Coflex interlaminar stabilization device.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 You asked the Plan to pre-approve Orthovisc. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orthovisc. Our reviewer says that 
Orthovisc is not medically necessary. Our physician reviewer found that the enrollee has osteoarthritis of the 
knee, and the requested medication is a new start. However, there is no indication that the enrollee has tried and 
failed the Plan's step one alternative. Also, there is no indication that the enrollee has a contraindication, to or 
would have an adverse effect from the Plan's preferred step one alternative. Therefore, the elements of 
coverage criteria have not been satisfied, and the requested service cannot be 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
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 the services requested are medically necessary. The 
Plan denied your request. The Plan says the criteria for approval have not been met. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #8 and #9. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee does not want endodontic 
therapy. The Plan denied your request. The Plan says that there was no evidence of pathological destruction to 
the teeth; therefore, the crowns are not medically necessary. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the crowns (D2740) for teeth #8 and #9 are medically necessary. Our physician reviewer found that the 
documentation indicates the presence of vertical fracture lines on tooth #8 and #9. In some cases, these 
fractures may be superficial. However, they also may be deeper and affect the integrity of the coronal structure 
of the teeth and lead to significant fractures. It is medically reasonable and necessary to place crown 
restorations to prevent further fracture and pulpal complications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2740) for tooth #8 and #9.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records do not show that the enrollee has any pulmonary complaints. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the enrollee had a CT scan of the chest in 
July 2021 that was read as showing mild hilar adenopathy. The CT was repeated on August 3, 2022, noting that 
the hilar lymph nodes had decreased slightly in size, although it was a non-contrast scan. The enrollee was seen 
for a well visit on August 14, 2023.  There is no indication of new respiratory symptoms and no mention of a 
repeat CT scan of the chest. Because the slightly enlarged lymph nodes in 2021 were shown to have improved 
1 year later, and the enrollee has no new respiratory findings or symptoms, a new repeat CT of the chest is not 
indicated. The denial is upheld. 
 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the thorax.
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 are being discharged home, but you feel you are 
not strong enough to walk without assistance. The Plan denied your request. The Plan says the SNF services 
you are requesting do not meet the requirements for approval. 
 
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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found when treating skin cancers, there is 
generally not a need for IGRT unless deep structures are being treated. The use of daily simple simulations for 
IGRT is not the standard of care for your diagnosis and is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L4-5, L5-SI anterior lumbar interbody fusion (20930, 
20936, 22558, 22585, 22845, 22853 x2). 
 
You asked the Plan to pre-approve an L4-5, L5-SI anterior lumbar interbody fusion. You say that this is 
medically necessary. The Plan denied your request. The Plan says this 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 an L4-5, L5-SI anterior lumbar 
interbody fusion. 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 documented spinal instability on any 
imaging study. The enrollee is a smoker and there is no documentation of adequate smoking cessation. 
 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 L4-5, L5-SI anterior lumbar interbody fusion have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an L4-5, L5-SI anterior lumbar interbody fusion (20930, 
20936, 22558, 22585, 22845, 22853 x2).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2740 x 7). 
 
You asked the Plan to pre-approve the dental services. You say that these procedures are necessary for a 
favorable long-term prognosis. The Plan denied your request. The Plan says that the request is not medically 
necessary. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the criteria for coverage have been met. Our physician reviewer found that the documentation indicates 
that core buildups (D2950) have been approved for these teeth which indicates significant coronal breakdown. 
Crown restorations are medically reasonable and necessary to provide adequate support for good masticatory 
function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve crowns (D2740 x 7).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve self-administered drug. 
 
You asked the Plan to pre-approve the medication. You say that this is 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 self-administered drug.   
Benefits for the medication 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve SNF services. You say that the contracted facility has a sub-par rating and 
the reviews are below expectations.  The Plan denied your request. The Plan says you have been authorized for 
admission to a contracted SNF. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The provider at issue in this case is not a network provider with the Plan. 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 services. Our reviewer says that these services can be provided by an 
in-network facility. Our physician reviewer found there is no evidence to show that the use of an OON SNF is 
medically necessary or reasonable. 
 
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 services have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve SNF services. Therefore, we decided that the Plan does 
not have to pre-approve Skilled Nursing Facility (SNF) services to be provided by an out-of-network (OON) 
provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on February 12, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the criteria was met for CPT 99284. 
 
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 a medically appropriate history and/or examination and high level 
of medical decision making." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the history and physical were 
expanded and problem focused. The medical decision making was not of high complexity. As such, the billing 
of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) rendered on February 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 30, 2023, billed 
with evaluation and management (EM) code 99233-GC. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim was billed with an invalid principal 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that manifestation diagnosis codes are never 
permitted to be used as first listed or principal diagnosis codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This claim was inappropriately billed with 
primary diagnosis code F05 which is a manifestation code. Therefore, we decided that the Plan does not have 
to pay for practitioner services provided on January 30, 2023, billed with evaluation and management (EM) 
code 99233-GC.
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 the services requested are medically necessary. The 
Plan denied your request. The Plan says the criteria for approval have not been met. 
 
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. 
 
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.