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 member can get the care he needs at 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 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 enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require at least 3 hours a 
day 5 days a week, or 15 hours over 7 consecutive days of therapy services. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Botox injections (J0585) at a dose of 400 units per 180 days. 
 
You asked the Plan to pay for Botox injections. You say that these services are medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says rules for Botox injections have not been met. 
 
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 pay for Botox injections. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found based on the medical records provided there 
is no documentation that the enrollee meets Local Coverage Determination (LCD): Chemodenervation 
(L33458) criteria for coverage for Botox injections at the requested dosage of 400 units per 180 days. The 
Medicare-approved drug compendia do not support the requested dosage and state that doses above 200 units 
do not provide any additional benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does 
not have to pay for Botox injections (J0585) at a dose of 400 units per 180 days.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network acupuncturist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available. 
 
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 referral to an out-of-network acupuncturist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OFEV 100mg 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 the requested drug is not covered under the medical plan. 
 
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 OFEV 100mg for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
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 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 
was admitted for non surgical management of an ankle fracture. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services with CPT code 73120 provided on May 8, 
2019. 
 
You asked the Plan to pay for CPT code 73120. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that 
two separate bilateral x-rays were provided on May 8, 2019. The file shows that the Plan paid for one set of 
bilateral x-rays (1 unit of 73120-26-LT and 1 unit of 73120-26-RT) provided on May 8, 2019. Therefore, we 
decided that the Plan does not have to pay for the x-ray services with CPT code 73120 provided on May 8, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assessment for prescription eye wear (92015) provided 
on February 10, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the assessment for prescription eye wear. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this service is not covered 
when received OON. 
 
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 these services when they are rendered by an in-network provider. 
 
We looked at the file and the Plan's rules. The file indicates that these services were rendered by an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the assessment for 
prescription eye wear have not been met. Therefore, we decided that the Plan does not have to pay for the 
assessment for prescription eye wear (92015) provided on February 10, 2020 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 power wheelchair (K0898). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that Power Mobility Devices are covered only 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 power wheelchair. Our reviewer 
says that the power wheelchair is not medically necessary. Our physician reviewer found the record shows that 
the enrollee has a mobility deficit but it is not clear that this deficit impairs participation in MRADLs in the 
home. The documentation does not clearly reveal why the mobility deficit is unable to be helped by an 
appropriately fitted walker or manual wheelchair. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (K0898).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions (D7210) to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve the extractions. You say that the services must be performed by an oral 
surgeon and are medically necessary. The Plan denied your request. The Plan says only services performed by 
a general dentist are covered. 
 
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 
dental extractions (D7210) to be provided by an oral surgeon.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits (97164). 
 
You asked the Plan to pre-approve the additional PT visits. You say that you feel the ongoing physical therapy 
is medically necessary to help with his balance. The Plan denied your request. The Plan says the additional 
physical 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 additional PT 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 The requested additional therapy is not generally accepted 
as specific and effective therapy for the patient?s condition. The enrollee has had extensive therapy for this 
condition and it does not appear that the enrollee requires the unique skills of a professional therapist to safely 
and effectively provide treatment, or that the services can be safely and effectively performed only by a 
therapist, or under the supervision of a therapist. The enrollee has been educated in a home exercise program. 
The  specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits (97164).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve brachytherapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that medical studies have not shown that this treatment is as good as other treatments. 
 
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 the therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found radiation is a standard approach to the treatment of skin cancer and is often the preferred approach to 
maximize cosmesis for facial lesion (as opposed to surgery). For lesions of the limbs and trunk, cosmesis is 
generally not a primary concern, as the cosmetic results after surgery are acceptable. Limb lesions are generally 
managed with surgery, although radiation is an accepted alternative. Many factors determine which of many 
treatments are best suited for an individual patient- including histology (squamous cell or basal cell carcinoma), 
size (T stage), depth, location, comorbidities. The enrollee was offered high dose rate surface brachytherapy. 
Surface brachytherapy for skin cancer is not a new modality, and historically this treatment approach has used 
radioactive sources to deliver the radiation, similar to what is being offered to this patient. The most recent 
NCCN guidelines state that radio-isotope brachytherapy can be considered for highly selected cases, though 
does not specify what selection criteria would be used. Thus, while NCCN guidelines do not advocate for 
routine use of brachytherapy for skin cancers, it is clear that several American societies consider it an accepted 
standard of care. Thus, standard medical necessity criteria are met for the treatment. 
 
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 therapy have been met. Therefore, we decided that the Plan has to pre-
approve brachytherapy for the enrollee.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee arthroscopic surgery (identified with CPT 
codes 29879 and 29880). 
 
You asked the Plan to pre-approve left knee arthroscopic surgery. 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 left knee arthroscopic surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found clinical exam findings have documented effusion and mildly limited in 
range of motion. There is radiographic evidence of moderate osteoarthritis. There is reported imaging evidence 
of medial and lateral meniscus tears. Conservative treatment has included medications and corticosteroid 
injections. Current evidence based medical literature would not support surgical intervention at this time. There 
is no documentation of mechanical symptoms. There is no documentation of positive meniscal signs or 
impingement on clinical exam. Detailed evidence of a recent, reasonable and/or comprehensive non-operative 
treatment protocol trial and failure has not been submitted. A corticosteroid injection was performed on 
November 11, 2020, with no documentation of response. Therefore, this request for left knee arthroscopic 
surgery is not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left knee arthroscopic surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve left knee arthroscopic surgery (identified with CPT codes 29879 and 29880).
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 needs assistance to learn how to walk on 
one leg. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been 
met. 
 
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 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 
was admitted for leukocytosis, non-healing ulcer of the leg (requiring below the knee amputation) and urinary 
tract infection. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that the 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Logisticare mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan 
denied your request. The Plan says the service is a covered benefit, but the enrollee exceeds limit set in the 
subscriber agreement. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles one-way.  
 
We looked at your request, the records in the case file, and the rules. The requested trip is for 91.8 miles. Based 
on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve additional Logisticare mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 29, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that lumbar epidural injections are only covered 
under certain medical indications.  
 
We looked at the file and Medicare rules. The file shows that bilateral injections at level L5 and S1 were 
requested. The Plan pre-approved an injection at 1 level. The rules say that no more than two transforaminal 
injections may be performed at a single setting (e.g. single level bilaterally or two levels unilaterally). Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a lumbar epidural injection.