Persius/hicric huggingface dataset:
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clinical trial services to be provided in California. 
 
You asked the Plan to pre-approve the clinical trial care. You say that this should be allowed since you have no 
local clinical trials available. The Plan denied your request. The Plan says clinical trial services cannot be 
approved by the Plan. If you are accepted into the trial, the routine costs will be paid by Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the clinical trial care as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve clinical trial services to be provided in California.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image guided lumbar decompression for 
the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is in stable condition, and not in a clinical trial. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the procedure is experimental. More research is needed to show safety and efficacy. It is not the standard 
of care and not better than convention treatment. It is not 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous image guided lumbar decompression for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the office 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 neither emergent nor urgent to 
provide out-of-network care. The Plan says they have in-network providers available to the enrollee that can 
provide the care you are requesting. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Continuous Glucose Monitor (CGM) 
(K0554, K0553). 
 
You asked the Plan to pre-approve the Dexcom G6. You say that the Dexcom G6 is medically necessary. The 
Plan denied your request. The Plan says the enrollee currently is using a Freestyle Libre CGM. A new CGM is 
not covered at this time. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a Freestyle Libre CGM. A Freestyle Libre CGM serves the same purpose as the 
Dexcom G6. No documentation was submitted to show that the Freestyle Libre CGM was damaged, has met 
it?s reasonable useful lifetime, or is otherwise unable to meet your  needs. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G6 Continuous Glucose Monitor (CGM) (K0554, K0553).
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member does not require a multidisciplinary level of care at this 
time. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve hereditary breast cancer genomic sequence analysis panel testing. 
 
You asked the Plan to pre-approve genetic testing. You say that the enrollee requires this testing due to her 
personal and family history, in order to provide the needed medical intervention. The Plan denied your request. 
The Plan says that the denial of authorization for this service is correct, because this testing cannot be 
considered reasonable and necessary for the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA1 and BRCA2 genetic testing are covered for 
enrollees who meet the above coverage criteria. 
 
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 genetic testing. Our reviewer says that 
the enrollee meets the Medicare criteria for the requested testing. Our physician reviewer found the enrollee has 
had breast cancer diagnosed at any age, and has at least 1 first, second, or third-degree relative with breast 
cancer at age 50 or younger. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve hereditary breast cancer genomic sequence analysis panel testing.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that this is medically necessary. The 
Plan denied your request. The Plan says that it is unknown why a regular bed will not suffice for the patient. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that a semi-electric hospital bed is not medically reasonable and necessary for the enrollee in this 
case. The case file does not contain medical documentation that the enrollee's condition requires position of the 
body in ways not feasible in an ordinary bed. The case file does not contain documentation that the enrollee 
requires frequent changes in body position, or that there is a need for immediate changes in body position. The 
documentation does not support that the enrollee's condition requires special attachments that cannot be fixed 
and used on an ordinary bed. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for a semi-electric hospital bed. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(S9986). 
 
You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. You say that you 
have high blood pressure and high cholesterol and require these benefits. The Plan denied your request. The 
Plan says you do not have a qualifying chronic diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The supplemental benefits at issue are not eligible for Medicare coverage. In this 
case, the plan?s rules apply. 
 
We looked at the plan?s rule, the file, and Medicare rules. The documentation provided shows that the enrollee 
does not have one of the qualifying diagnoses listed in the Evidence of Coverage. Based on this information, 
we decided that Medicare rules for coverage of the special supplemental benefits for the chronically ill have not 
been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for 
the chronically ill (S9986).
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 want to have therapy in order to get stronger and 
better. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do require physical therapy and occupational therapy services, but based on the medical records provided 
you do not require an intensive inpatient rehabilitation therapy program. Our physician reviewer also found that 
based on the medical records provided, there is concern that you will not be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at 
the skilled nursing facility level appears to be more appropriate in this case. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you need a scooter to get out of the house. 
The Plan denied your request. The Plan says that you do not meet medical necessity criteria. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. A power wheelchair serves the same purpose as a power 
scooter. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left diagnostic facet injections. 
 
You asked the Plan to pre-approve the left diagnostic facet injections. You say that you are in constant pain and 
cannot sleep for more than an hour at night due to this pain. You say that your primary care physician gave you 
chiropractor approved exercises to do, but you feel worse after doing them. The Plan denied your request. The 
Plan says the guidelines for coverage require that there are notes from the doctor that say there is a plan to 
injection no more than three joint levels at a time. The Plan says that the notes provided in this case, do not say 
that. 
 
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 left diagnostic facet injections. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested procedure is supported for predominantly axial pain that is not 
associated with radiculopathy or neurogenic claudication.  Radiculopathy is documented in the provided notes. 
The medical records do not document the specific levels, nor the number of levels, the prescriber plans to 
inject. 
 
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 left diagnostic facet injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve left diagnostic facet injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan services. 
 
You asked the Plan to pre-approve the CT scan services. You say that the records provided support the need for 
the requested CT scan. The Plan denied your request. The Plan says the clinical information provided does not 
meet the criteria for coverage. 
 
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 services. Our reviewer says 
that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found an 
ultrasound has been performed on the neck and a normal appearing node was noted.  There is no 
documentation of abnormal lymphadenopathy. There is no indication for CT scan of chest with IV contrast for 
the diagnosis of lymphadenopathy, as there has not been any studies demonstrating abnormal lymphadenopathy 
and no other reason was given for study. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve computed tomography (CT) scan services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator and supplies to be provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve oxygen equipment. You say that this provider's services would be a valuable 
resource for the enrollee. The Plan denied your request. The Plan says the denial of authorization for these 
items is correct, because this provider is out-of-network with the Plan and these items can be provided by an in-
network supplier. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a non-invasive ventilator and supplies to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darbepoetin Alfa (J0881). 
 
You asked the Plan to pre-approve the Darbepoetin Alfa. The Plan denied your request. The Plan says the 
information submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 the Darbepoetin Alfa. Our reviewer 
says that Darbepoetin Alfa is not medically necessary. Our physician reviewer found the documentation does 
not support previous use or contraindications to this medication.  Our reviewer also found that, without the 
support of the documentation, medical necessity cannot be determined. 
 
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 Darbepoetin Alfa have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Darbepoetin Alfa (J0881).