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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that the admission to an IRF 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 that you have fundamental rehabilitation needs and do not require intensive or 
complex rehabilitation. You do not require frequent physiatry oversight. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower partial dentures (D5226), and upper partial 
dentures (D5225, D5213). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 on date of service February 25, 2019. 
Therefore, we decided that the Plan does not have to pre-approve lower partial dentures (D5226), and upper 
partial dentures (D5225, D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor. The Plan denied your request. The Plan says 
you do not require insulin three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the a 
FreeStyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre 2 sensor.
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's medical management and rehabilitation 
requires an inpatient rehabilitation stay and close physician supervision. The Plan denied your request. The 
Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of care 
such as a skilled nursing facility. 
 
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 patient's 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. There is not a reasonable expectation that this 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that you need the PET scan to distinguish if you 
have Alzheimer's or other forms of dementia. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records provided for review only 
supported a diagnosis of a mild cognitive impairment (MCI). Therefore, the requested service would not meet 
Medicare requirements for coverage. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extracapsular cataract removal with insertion of 
intraocular lens prosthesis (1-stage procedure), manual or mechanical technique, without endoscopic 
cyclophotocoagulation (66984). 
 
You asked the Plan to pre-approve cataract surgery. You say that the enrollee was denied for cataract surgery, 
and you would like to appeal. The Plan denied your request. The Plan says under Medicare guidelines, the 
request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve cataract surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has significant ocular history and recent surgery in right eye of which the focus of 
most of the clinical notes.  The notes failed to documented the following for the left eye: 
 
1) No documentation of visual complaints in left eye and how it affects day to day function and quality of life. 
2) Failure to test best corrected visual acuity with manifest refraction of left eye. 
3) Failure to perform comprehensive eye exam or failure to document so, specifically no fundus exam for left 
eye. 
4) Enrollee with other ocular co-existing disease process of Fuch's endothelial dystrophy in left eye but failure 
to indicate whether this disease process, cataract, or both is contributing to left eye blurred vision. 
 
Overall, a more thorough exam and documentations of enrollees left eye condition warranting the 
recommendation for cataract surgery for left eye 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 cataract surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage 
procedure), manual or mechanical technique, without endoscopic cyclophotocoagulation (66984).
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 meets the full criteria for the inpatient 
rehabilitation based on his current condition, functional deficits, and multiple comorbidities. The Plan denied 
your request. The Plan says is not medically necessary, and the enrollee's needs can be met at a lower level of 
care such as a skilled nursing facility. 
 
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 had heart failure and unsteadiness with ambulation. The enrollee was 
treated with medical therapy and has participated in therapy and is now able to ambulate with a walker and 
assistance from another person. The enrollee is medically stable. The documentation shows that 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. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. There is not a reasonable expectation that this 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 surgical removal of erupted tooth (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 on date of service January 9, 2023. 
Therefore, we decided that the Plan does not have to pre-approve surgical removal of erupted tooth (D7210).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary for the 
enrollee to fully recover and successfully regain maximum independence. The Plan denied your request. The 
Plan says the enrollee's medical needs are being met in the current 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 enrollee appears to be improving on treatment and should only require short-term 
additional acute care services that can safely be provided at the current facility until more appropriate for 
transfer to a lower level of care.  The enrollee does not require services at the LTACH that are not already available at the current 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 the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device. 
 
You asked the Plan to pre-approve interlaminar stabilization device. You say that this treatment is considered 
safe and effective. The Plan denied your request. The Plan says there is insufficient evidence for the efficacy of 
this procedure. 
 
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 interlaminar stabilization device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found interlaminar stabilization devices are experimental in spine surgery. 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 interlaminar stabilization device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve insertion of an interlaminar stabilization device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eyewear purchased on February 1, 2023. 
 
You asked the Plan to pay more for the eyewear. You say that you have a separate policy through the county 
directly with the eye insurance company. You also say that whatever the eye insurance company paid in the 
past was not through your Medicare Advantage plan. The Plan denied your request. The Plan says the 
maximum allowance for vision services has already been paid by the Plan, and no further payment is due. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $150 once every 24 months towards the cost of eyewear. 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that the Plan has paid $150 toward 
your eyewear purchased on February 1, 2023. Based on this information, we decided that the Plan's rules for 
coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay more for 
the eyewear purchased on February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) and prefabricated 
post and core in addition to crown (D2954). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 on date of service November 17, 2020, and 
November 19, 2020. Therefore, we decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) and prefabricated post and core in addition to crown (D2954).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alpha Thalassemia DNA analysis (81275). 
 
You asked the Plan to pre-approve the genetic testing. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria and this request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the only way to make diagnosis of Alpha Thalassemia is with genetic testing. 
However, this enrollee has mild anemia and specific determination will not benefit this enrollee. 
  
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Alpha Thalassemia DNA analysis (81275).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown (D6751) and pontic (D6241). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted on this 
claim. 
 
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. Therefore, we decided that the Plan does 
not have to pre-approve retainer crown (D6751) and pontic (D6241).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
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 although improving, has ongoing acute medical issues and still requires 
acute care services. 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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic (D6242) and a retainer crown (D6740). 
 
You asked the Plan to pre-approve pontic and crown. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 pre-approve 
pontic (D6242) and a retainer crown (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation  per quadrant (D4921) provided on 
November 29, 2022. 
 
You asked the Plan to pay for the gingival irrigation  per quadrant. You say that your dentist requested you 
have these procedures done as they are concerned about the deterioration of your gums and you interpreted this 
as necessary to maintain your teeth and have less pain in your gums. You also say that you have attached 
medical records from your dentist for our reconsideration. The Plan denied your request. The Plan says 
procedure code D4921 is not listed as covered by the Plan's dental 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. 
 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 gingival 
irrigation  per quadrant (D4921) provided on November 29, 2022.