Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of skin tags (11201). 
 
You asked the Plan to pre-approve the removal of skin tags. You say that you would like reconsideration 
because the skin tags are causing you pain. The Plan denied your request. The Plan says the notes from your 
doctor do not show that your skin tags are causing you bleeding, intense itching or pain. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 removal of skin tags. Our reviewer 
says that you do not meet LCD criteria for this procedure. Our reviewer found the records indicate that the skin 
tags are asymptomatic and present a cosmetic rather than medical problem. 
 
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 removal of skin tags have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the removal of skin tags (11201).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Computed Tomography (CT) of the Chest (71250). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
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 medically necessary. Our physician reviewer found a prior Esophagogastroduodenoscopy (EGD) 
identified an abdominal mass. Ultrasound found hepatic and pancreatic cysts. The CT is reasonable for further 
evaluation. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Computed Tomography (CT) of the Chest (71250).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical and occupational therapy to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve physical and occupational therapy. You say that without the services she 
will not improve. You say that therapy within the facility is necessary to not put herself and other community 
members at risk. The Plan denied your request. The Plan says services are available in-network. The Plan also 
says that therapy can be requested through home health 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pre-approve physical and occupational therapy to be 
provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device services. 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device 
services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested 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 insertion of interlaminar/interspinous 
process stabilization/distraction device services. 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 
spinal stenosis. There is no documentation supporting spinal instability. The spacer remains experimental at 
this time. More research is needed to show the safety and efficacy of the device. Therefore, the enrollee does 
not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of 
interlaminar/interspinous process stabilization/distraction device services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (scooter). 
 
You asked the Plan to pre-approve scooter. You say that you need this scooter that can fit in your car to aid 
with outings. The Plan denied your request. The Plan says the denial of authorization for this device is correct, 
because you already have a Group 3 power wheelchair that meets your needs. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. You already have a Group 3 power 
wheelchair that meets your needs for use inside of the home. Therefore, we decided that the Plan does not have 
to pre-approve a power operated vehicle (scooter).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you're not able to move from your wheelchair 
into your shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies provided from August 20, 2019 to 
August 24, 2019. 
 
You asked the Plan to pay for the infusion supplies. The Plan denied your request. The Plan says the 
documentation did not include a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
infusion supplies provided from August 20, 2019 to August 24, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of veins with lasers. 
 
You asked the Plan to pre-approve treatment of veins with lasers. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatment of veins with lasers is covered for certain 
indications. 
 
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 treatment of veins with lasers. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found you were diagnosed with chronic venous insufficiency and complain 
of leg pain and swelling on the right leg for the past 7 -8 months. You had tried more than three months of 
conservative treatments including compression stocking, leg elevation, exercise, weight loss and analgesics 
without relief. The documentation does not support that you have a diagnosis, condition, and/or symptoms that 
meet the Medicare criteria for coverage of treatment of veins with lasers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment of veins with lasers have not been met. Therefore, we decided that the 
Plan does not have to pre-approve treatment of veins with lasers.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve BiPAP respiratory assist device (E0470), 
 
You asked the Plan to pre-approve the BiPAP device.. You say that you would like reconsideration because 
you are working with your doctor to become compliant with your current device. The Plan denied your request. 
The Plan says that you have not used your current device in the prescribed manner. 
 
The Plan follows Medicare rules. Medicare rules say that continued coverage of a PAP device beyond the first 
three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating 
therapy, the treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is 
benefiting from PAP therapy. 
 
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 BiPAP device.. Our reviewer says 
that given the life-threatening pulmonary hypertension and clinical importance of using the PAP device to 
achieve adequate oxygenation at night, PAP is considered medically necessary, and it is reasonable to give you 
another opportunity to achieve compliance. Our physician reviewer found coverage for an additional 3 months 
is medically reasonable and 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 BiPAP device. have been met. Therefore, we decided that the Plan has to 
pre-approve BiPAP respiratory assist device (E0470).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested 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 neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was evaluated by a Sleep Medicine physician on February 28, 
2020 for follow-up of obstructive sleep apnea, Restless legs syndrome, and hypersomnia. It is documented that 
the enrollee "continues to be very concerned regarding cognitive/memory loss". The enrollee expressed 
concern about early Alzheimer's disease. The enrollee wanted to be assessed even though he wasn't sure there 
would be any helpful intervention. There is no documentation that the enrollee in this case has undergone more 
basic evaluation, such as a Mini Mental State Examination or an extended mental status examination. 
Therefore, the enrollee does not meet criteria for the requested services. 
 
Review of the file shows that the plan mentions using Local Coverage Determination, LCD L34646 to support 
their denial. However, LCD L34646 is not valid for the enrollees home state. Therefore, we cannot 
utilize L34646 to substantiate our decision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a Monovisc injection. 
 
You asked the Plan to pre-approve a Monovisc injection. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the 
requested services. 
 
The Plan follows Medicare rules. Medicare rules say that Monovisc is covered for certain indications. 
 
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 Monovisc injection. Our reviewer 
says that the documentation supports that the requested Monovisc injection is medically reasonable and 
necessary. Our physician reviewer found the enrollee has a diagnosis of osteoarthritis of the left knee. The 
enrollee has 9 out of 10 pain despite treatment with medication, home exercises, and one steroid injection. The 
enrollee has failed to respond to aspiration of the knee when effusion is present and intra-articular 
corticosteroid injection therapy when inflammation is a significant component of the patient's symptoms and 
intra-articular corticosteroids are not contraindicated. The enrollee is symptomatic, the clinical diagnosis is 
supported by radiologic evidence of osteoarthritis of the knee, the enrollee has failed at least three months of 
conservative therapy and an intra-articular corticosteroid injection. Therefore, the enrollee meets criteria for the 
requested Monovisc. 
 
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 Monovisc injection have been met. Therefore, we decided that the Plan has to 
pre-approve a Monovisc injection.  
 
 
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: 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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above. 
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are admitted to a 
skilled nursing facility because of traumatic brain injury associated with a subarachnoid hemorrhage. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the record supports a need for physical and occupational therapy, it does not support a 
need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 LTACHs are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short term acute care hospitals. In this case, 
ongoing care needs include respiratory support with BiPAP, surveillance laboratory studies, and intense 
therapy services. The documentation does not support that the enrollee in this case requires services at the 
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not meet criteria for LTACH admission. 
 
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. The patient 
appears to be requiring ongoing acute care services for the short-term, however, it is not clear that he is stable 
enough for transfer. The patient does not require services at the LTACH that are not already being provided in 
the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for LTACH services. 
 
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neupogen for the enrollee. 
 
You asked the Plan to pre-approve the drug. 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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not support that the Neupogen is medically reasonable and necessary for a patient who is undergoing both 
radiation and chemo. Although Neupogen might be effective at increasing WBC count in this enrollee, 
evidence suggests using Neupogen in the setting of both chemotherapy drugs and radiation therapy may 
increase risk, including interference with myeloid cell division. So, it would not be safe in this case as the 
enrollee is using both chemo and radiation therapies. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neupogen for the enrollee.