Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments for teeth 22 and 27 (D6057 
x2). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service 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 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 the requested item or service was exhausted with the approval of custom fabricated 
abutments for teeth 5 and 12. Therefore, we decided that the Plan does not have to pre-approve custom 
fabricated abutments for teeth 22 and 27 (D6057 x2).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is 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 complexity of your nursing, medical, and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. 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 inpatient 
rehabilitation facility. The medical records do not support that you would meet the criteria for admission to an 
acute inpatient rehabilitation facility. You can receive further services 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: 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 requires extensive inpatient therapy. The 
Plan denied your request. The Plan says the enrollee's condition does not meet all of the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (Life 2000). 
 
You asked the Plan to pre-approve the Life 2000 device. You say that this was prescribed to help manage his 
complicated respiratory needs at home. You say that this has been ordered in addition to the enrollee's current 
non-invasive therapy not be used as a backup but to be used to meet a different medical need than their current 
therapy can provide. 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 the Life 2000 device. Our reviewer says 
that the requested Life 2000 device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that the enrollee has severe chronic obstructive 
pulmonary disease (COPD) with obstructive sleep apnea (OSA) and pulmonary hypertension. The Life2000 system is not a true ventilator because it is not capable of providing full ventilatory support. It is intended to be 
used during activity, and there is inadequate evidence that it is beneficial in the treatment of any chronic lung 
disease. Therefore, the reviewer found that the requested Life 2000 device 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 Life 2000 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator (Life 2000).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient behavioral health treatment with an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve outpatient behavioral health treatment with an OON provider.. You say that 
you want to see a provider who does virtual visits. You say that the network provider you've contacted have not 
been able to see you due to their lack of staff and inability to care for your medication management.  The Plan 
denied your request. The Plan says they have female medical doctors (MDs) with expertise in the treatment of 
resistant depression who can see the enrollee and who offer virtual services.  
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services with an OON provider. Therefore, we decided that the Plan does not have to 
pre-approve outpatient behavioral health treatment with an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexwalk system (L5981) and multiaxial rotation unit 
(L5986). 
 
You asked the Plan to pre-approve a flexwalk system and multiaxial rotation unit. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Lower Limb Prostheses are 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 a flexwalk system and multiaxial 
rotation unit. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
physician documentation is not consistent that the enrollee is a K3 ambulator. The enrollee uses crutches to 
ambulate and was using crutches prior to amputation due to non-weight bearing ulceration. The request 
exceeds the enrollee's functional needs. 
 
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 flexwalk system and multiaxial rotation unit have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a flexwalk system (L5981) and multiaxial rotation unit 
(L5986).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BMP allografts (20930 x2). 
 
You asked the Plan to pre-approve BMP allografts. You say that this is medically necessary. The Plan denied 
your request. The Plan says this has not been shown to be better of safer than standard bone grafts. 
 
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 BMP allografts. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BMP allografts have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BMP allografts (20930 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office consultation and evaluation and management services 
provided by a chiropractor on January 31, 2023, to February 28, 2023. 
 
You asked the Plan to pay for the office consultation and evaluation and management services provided by a 
chiropractor. You say that the chiropractic services in dispute worked and you were told by the Plan that 50% 
would be covered. The Plan denied your request. The Plan says the services provided are non-covered by 
Medicare and under your contract. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for office consultation and evaluation and management services provided by 
a chiropractor on January 31, 2023, to February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, (RFA) nerves innervating the 
sacroiliac joint (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee reports 75% relief from 2 
blocks and pain has been present more than 3 months. RFA is medically necessary. The Plan denied your 
request. The Plan says this procedure is considered an experimental/investigational procedure because of the 
wide variation in efficacy reported in the literature. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found RFA of the sacroiliac joint is experimental and investigational. More medical 
research is needed to support this is safe and effective for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation, (RFA) nerves innervating the sacroiliac joint (64625).
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 requesting an appeal on behalf of the 
enrollee for acute inpatient rehabilitation. The Plan denied your request. The Plan says based on the available 
information, an IRF admission is not reasonable and 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 the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  Our reviewer also found that the enrollees care needs can be met 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 1, 2023, billed with 
procedure code 99214. 
 
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 two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that M54.17 has an Excludes1 note in relation to M47.26. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does 
not have to pay for practitioner services provided on May 1, 2023, billed with procedure code 99214.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown (D2740) and core buildup (D2950) for tooth #8 
and #9. 
 
You asked the Plan to pre-approve the dental services. You say that you need assistance with the dental work 
and crowns are covered. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the damage to the teeth is minor and is due to attrition and abrasion the core buildup 
is denied because there is insufficient retention for a separate extra coronal restorative procedure. 
 
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 and core buildup are not medically necessary. Our physician reviewer found that the 
documentation provided indicate that teeth #8 and #9 do not exhibit significant coronal breakdown due to 
caries or fracture to warrant core buildup and crown restorations. 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve crown (D2740) and core buildup (D2950) for tooth #8 and #9.
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 requesting reconsideration of the denied IRF 
admission. The Plan denied your request. The Plan says IRF care is not reasonable and 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 complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The medical records do not support that 
the enrollee would meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can 
receive further services 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 a percutaneous vertebral augmentation (PVA) (22514). 
 
You asked the Plan to pre-approve the PVA. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the records do not show that the enrollee's vertebral compression fracture is 
chronic. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation (PVA) 
procedures will be considered medically reasonable and necessary for painful, debilitating, osteoporotic 
vertebral collapse/compression fractures, defined as those that have not responded to non-surgical medical 
management (e.g. narcotic and/or non- narcotic medication, physical therapy modalities) with and without 
methods of immobility (e.g. rest, bracing). 
 
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 PVA. Our reviewer says that the 
requested PVA is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed conservative treatment, such as fracture bracing. Therefore, the reviewer found that the requested PVA is not medically reasonable or 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 the PVA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a percutaneous vertebral augmentation (PVA) (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig (A9282) provided on April 4, 2023. 
 
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) 
provided on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you do not feel safe using ride sharing 
services. The Plan denied your request. The Plan says additional trips beyond what the benefit allows are not 
covered. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.