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 the enrollee is willing and able to participate in 3 
hours of therapy daily, and prior level of function shows potential significant improvement. The Plan denied 
your request. The Plan says an intensive rehabilitation program 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 enrollee's medical status does not currently require intensive physician and 
nursing oversight only in an IRF. Our reviewer also found that the enrollee may benefit from multiple therapies 
such as physical and occupational therapy, but the documentation does not support that the enrollee's functional 
status requires an 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you believe getting the denture 
is medically necessary. The Plan denied your request. The Plan says that the service is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
mandibular partial denture 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 mandibular partial denture. Our 
reviewer says that a mandibular removable partial denture meets the criteria for coverage. Our physician 
reviewer found replacement of missing tooth #'s 30 and 31 would prevent the extrusion of tooth #'s 2 and 3, 
and stabilize your occlusion providing good masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the mandibular partial denture have been met. Therefore, we decided that the 
Plan has to pre-approve a mandibular partial denture (D5214).  
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on August 20, 2020 with swelling and drainage from an incision from a previous right total knee 
arthroplasty and rectal bleeding. The swelling and drainage were due to hemarthrosis. The rectal bleeding was 
felt secondary to anticoagulation and colonoscopy did not reveal bleeding. The most recent physical and 
occupational therapy notes dated August 24, 2020 and August 27, 2020 state he is walking 250 feet with a 
rolling walker and assistance and needs supervision for bed mobility and transfers. The complexity of his 
nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an 
intensive therapy program 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 the CTA of abdomen and pelvis, with contrast 
material(s) (CPT Code 74174), for the enrollee. 
 
You asked the Plan to pre-approve the CTA. You say that the enrollee had a decline in health since the CTA 
was done. The Plan denied your request. The Plan says there is an approval code for the same study, or a 
similar study, that is on file in the member's records. The Plan states this approval is still in effect and the 
clinical information submitted does not describe results of this prior imaging, or if there are plans to use this 
approval. The Plan states the approved study may be sufficient for the evaluation of the current clinical 
condition and guidelines do not support additional imaging without knowing the outcome of the prior approval 
and, therefore, the request is not indicated at this time. 
 
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 CTA. Our physician reviewer found 
the enrollee had a CTA of chest, abdomen and pelvis on July 30, 2020. It demonstrated previous repair of 
descending thoracic aneurysm with aortic measurements similar to computerized tomography (CT) from June 
29, 2020. Other findings included mediastinal and hilar adenopathy and bilateral pulmonary opacities. The 
recommendation was for 6-12 month follow up for lymphadenoapthy and pulmonary opacities. The only 
clinical information submitted was in the appeal letter which states that the enrollee has had a decline in their 
health since the last CT. No specifics are included. The requested CT Scan is not 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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CTA of abdomen and pelvis, with contrast material(s) (CPT Code 74174), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty surgery to be provided at the out-
of-network hospital. 
 
You asked the Plan to pre-approve the total hip arthroplasty surgery to be provided at the out-of-network 
hospital. You say that your orthopedic surgeon performed a total hip replacement on your left hip in 2015 and 
you do not want to go to another orthopedic surgeon. The Plan denied your request. The Plan says you must 
receive your care from a network provider. In most cases, care you receive from a non-network provider (a 
provider who is not part of our plan's network) will not be covered. 
 
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 hospital 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. Therefore, we decided that the Plan does not have to pre-approve the total 
hip arthroplasty surgery to be provided at the out-of-network hospital.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee had an elective left 
hip replacement on August 18, 2020 and was discharged home on August 19, 2020 with home health orders. 
She has had multiple joint replacements and is unable to use a rolling walker or complete basic bed mobility 
tasks without extensive assistance. The complexity of her medical, nursing, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may 
benefit from further therapy but does not require an intensive therapy program 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve outpatient facial surgery. 
 
You asked the Plan to pre-approve grafting of autologous soft tissue (15769) and surgical repair (Closure) 
procedures on the integumentary system (15828). You say that the enrollee needs the surgery to help be 
accepted. The Plan denied your request. The Plan says that the requested surgeries are not coverable under 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 grafting of autologous soft tissue 
(15769) and surgical repair (Closure) procedures on the integumentary system (15828). Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found facial feminization surgery is medically reasonable and necessary for the enrollee in this case, as the goal 
of transgender care is to address emotional, hormonal, and physical sources of distress. Male facial features and 
hairline in a transgender woman is a physical issue which is treatable. Gender affirming/confirming surgery 
plays an undisputed role in contributing toward favorable outcomes. This medically necessary treatment will 
give the enrollee the best chance to pass in society as a fully functional female. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of grafting of autologous soft tissue (15769) and surgical repair (Closure) 
procedures on the integumentary system (15828) have been met. Therefore, we decided that the Plan has to 
pre-approve outpatient facial surgery.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 100 Units/ML Vial Novolog. 
 
You asked the Plan to pre-approve the Novolog. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's 
condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 100 Units/ML Vial 
Novolog.  
 
Benefits for the Novolog may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sulfasalazin for the enrollee. 
 
You asked the Plan to pre-approve Sulfasalazin. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that this medication is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sulfasalazin for the 
enrollee.  
 
Benefits for Sulfasalazin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric patient lift and power lift base kit. 
 
You asked the Plan to pre-approve a patient lift, electric with seat or sling (E0635) and power lift base kit 
(E1399). You say that your spouse cannot operate a manual lift. The Plan denied your request. The Plan says 
the medical notes do not support why an electric lift is needed over a  standard hydraulic lift. 
 
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 a patient lift, electric with seat or sling 
(E0635) and power lift base kit (E1399). Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee meets the requirement for patient lift, electric with seat or 
sling (E0635) and power lift base kit (E1399). The records do not provide a clinical confirmation as to why the 
standard hydraulic lift cannot be used. 
  
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 patient lift, electric with seat or sling (E0635) and power lift base kit (E1399) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric patient lift and 
power lift base kit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional occupational therapy visits. 
 
You asked the Plan to pre-approve the 6 additional occupational therapy visits. You say that you have had slow 
progress after a stroke and therapies are helping you to make progress, in addition to what you do at home. You 
say that you are a long way from being independent. You say that electrical stimulation and other equipment is 
being used in the offices. The Plan denied your request. The Plan says the additional occupational therapy visits 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 6 additional occupational therapy 
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found there is no documentation that the 
additional requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. 
The enrollee has had ten therapy sessions and has met his goal of demonstrating independence and compliance 
with the home exercise program. This can be continued for further improvement of his condition. There is no 
documentation that the additional requested therapy requires the unique skills of a professional therapist to 
safely and effectively provide treatment, that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. The enrollee has had ten therapy sessions authorized and 
has met his goal of demonstrating independence and compliance with the home exercise program. This can be 
continued for further improvement of his 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 the 6 additional occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 6 additional occupational therapy visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transport to a physician's office. 
 
You asked the Plan to pre-approve the services. You say that you have a life-threatening condition, and it is 
impossible to safely transport you by any other means. The Plan denied your request. The Plan says 
transportation by ambulance to a physician's office is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office. 
Therefore, we decided that the Plan does not have to pre-approve non-emergency transport to a physician's 
office.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that you require a new 
mattress. The Plan denied your request. The Plan says that you don't meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a group 2 support surface is covered for the 
above criteria. 
 
We looked at the file and Medicare rules. The file does not indicate you have any open wounds. Based on this 
information, we decided that Medicare rules for coverage of a powered pressure-reducing air mattress have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air 
mattress (E0277).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone scan (78803). 
 
You asked the Plan to pre-approve the bone scan. You say that the scan is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that SPECT imaging is covered when 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 bone scan. Our reviewer says that 
the requested bone scone is not medically necessary. Our physician reviewer found there was not any 
information submitted that suggested the diagnosis of osteomyelitis. Labs were not elevated. Plain films were 
not ordered. The study is not indicated based on records provided. 
 
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 bone scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bone scan (78803).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says MRADLs in the home can be addressed with a four wheeled walker with a seat. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no 
documentation that you have a personal mobility deficit that impairs participating in MRADLs. It appears that 
your mobility deficit can be sufficiently managed using a four-wheeled walker. There is no documentation that 
you can safely operate a personal mobility device. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 standard power wheelchair.