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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel you can benefit from intensive 
rehabilitation. You also say that your needs cannot be met at a skilled nursing facility. The Plan denied your 
request. The Plan says the records show you do not have a need for intensive rehabilitation, complex medical 
conditions which require physician supervision, and a multidisciplinary team for your care. The Plan also says 
that you can safely receive the services you need in other settings, for example: a skilled nursing facility, home 
with home health and home physical 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. Our 
physician reviewer also found that there is not a reasonable expectation that you 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you have an important appointment. 
The Plan denied your request. The Plan says additional transportation cannot be added after you have utilized 
the maximum number of trips allowed per year. 
 
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 a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cystourethroscopy services (CPT 52224) provided to the 
enrollee on January 28, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 52224-51 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 52224 is cystourethroscopy, with fulguration or 
treatment of minor lesion(s) with or without biopsy.
 
We asked our coding 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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
operative report does not include documentation to support CPT 52224. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for cystourethroscopy services (CPT 52224) provided to the enrollee on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteogenesis stimulator, low intensity ultrasound, non-
invasive (CPT Code E0760). 
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the osteogenesis stimulator have not been met. Your records do not 
indicate nonunion of a fracture following a 90 day period of healing. Therefore, we decided that the Plan does 
not have to pre-approve osteogenesis stimulator, low intensity ultrasound, non-invasive (CPT Code E0760).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DME from an out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that you need the prosthetic to help mobility and you are 
dissatisfied with the other DME provider. The Plan denied your request. The Plan says the services can be 
provided in-network. 
 
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 
DME from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mouth appliance for jaw pain. 
 
You asked the Plan to pre-approve mouth appliance for jaw pain. You say that the item is necessary. The Plan 
denied your request. The Plan says neither Medicare nor your health plan covers this item. The Plan states 
items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures 
directly supporting the teeth are not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mouth appliance for jaw pain have not been met. Therefore, we decided that the Plan does not have 
to pre-approve mouth appliance for jaw pain.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Nivolumab (J9299) 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 that the FDA does not approve monotherapy with OPDIVO for metastatic 
adenocarcinoma of lung and therefore will not approve it. 
 
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 medically reasonable and necessary. Our physician reviewer found this can be approved due 
to Micromedex, which allows OPDIVO/Nivolumab as a first-line treatment for PDL1+ disease. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
Nivolumab (J9299) 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: 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 physicians support that the LTACH 
is the appropriate level of care. You say that the enrollee has exceeded the criteria for an LTACH admission. 
The Plan denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 that the enrollee does not require services at the LTACH that are not already 
available at the current facility. Our reviewer says that continued care at the current facility would be 
appropriate until stable for discharge to a lower level of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that 
the Plan requires the enrollee to receive care from providers who are part of the enrollee's primary care 
physician's (PCP) specialty network. 
 
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 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 
requested physician's services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical 
history of diabetes, hypertension, hyperlipidemia, hypothyroidism and mild dementia who has been in an acute 
rehabilitation facility for treatment after a stroke on 09/11/2020. She has been treated in the rehabilitation 
facility with physician oversight and with physical and occupational therapy. She is walking 500 feet with 
stand-by assist/contact guard assistance and is supervision to minimal assist for most transfers and activities of 
daily living. She is medically stable. Medical records indicate the rehabilitation team has recommended 
discharge to home with home health services but the family is requesting transfer to a skilled nursing facility 
for skilled nursing and therapy services is requested.  
 
Based on the medical records provided there is no documentation that the enrollee requires skilled nursing 
services on a daily basis. The enrollee does require skilled therapy services; however, these are not needed on a 
daily basis. In this case, the enrollee does not require the services on an inpatient basis, in a skilled nursing 
facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting 
additional routine transportation trips. The Plan denied your request. The Plan says you exhausted your benefit. 
 
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 a maximum of six (6) one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The seventh (7th) 
trip and beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy. 
 
You asked the Plan to pre-approve knee arthroscopy. You say that the requested knee arthroscopy is medically 
necessary. The Plan denied your request. The Plan says the requested knee arthroscopy is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve knee arthroscopy. Our reviewer says 
that the requested knee arthroscopy is not medically necessary. Our physician reviewer found this enrollee 
presents with a history of worsening right knee pain. There is no history of trauma. Clinical exam findings have 
documented medial joint line tenderness and positive patellofemoral grind. There is reported radiographic 
evidence of medial compartment collapse and patellofemoral joint space narrowing, with no x-ray report 
provided for review. There is imaging evidence of medial meniscus and lateral meniscus tearing, with moderate 
medial compartment osteoarthritis and mild lateral and patellofemoral compartment osteoarthritis. She had 
failed to improve with conservative treatment, including activity modification, physical therapy, and home 
exercise program. Under consideration is a request for knee arthroscopy (CPT code 29882). Current evidence 
based medical literature would not clearly support meniscal surgery at this time. There is no documentation of 
mechanical symptoms or positive meniscal testing on clinical exam to support meniscal surgery in the setting 
of at least moderate osteoarthritis. There is no clear evidence that the meniscal pathology is the source of pain 
for this enrollee. Therefore, this request for knee arthroscopy (CPT code 29882) is not medically reasonable 
and 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 knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee arthroscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor treatment field therapy. 
 
You asked the Plan to pre-approve the requested services. You say that Optune in combination with 
temozolomide is the most appropriate option for the enrollee at the present time. The Plan denied your request. 
The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The documentation confirms the enrollee has recurrent anaplastic 
astrocytoma. Tumor treatment field therapy is not reasonable and necessary for the treatment of recurrent 
disease. 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 tumor treatment field therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), 
with any type side rails, with mattress (CPT Code E0260). 
 
You asked the Plan to pre-approve the DME. You say that the item should be covered by the Plan. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 DME. Our physician reviewer 
found review of the records do not support the enrollee meets the advanced requirements of an electric hospital 
bed. There is no immediate need for change in body position noted in the record. 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress 
(CPT Code E0260).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CT scan, cervical spine; without contrast material 
(CPT Code 72125). 
 
You asked the Plan to pre-approve the CT scan. You say that you are in severe pain in your back and shoulders. 
The Plan denied your request. The Plan says the CT is not medically necessary. 
 
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 physician reviewer 
found there is no documented examination of the cervical spine was noted, nor was there report or evidence 
documented of you having tried conservative treatments for the cervical spine or signs of a red flag diagnosis. 
Also, there was no evidence of an x-ray being performed on the cervical spine. Therefore, this request for CT 
cervical spine will be considered not medically necessary due to lack of supportive documentation for such a 
test. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CT scan, cervical spine; without contrast material (CPT Code 72125).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be rendered by the out of network 
(OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are available providers within the network that can 
render the requested service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve cataract 
surgery to be rendered by the out of network (OON) provider.
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 denial should be overturned so the enrollee can 
regain maximum functional potential to return to home. You say that the medical management and rehab needs 
require an inpatient stay and close physician/nurse supervision. The Plan denied your request. The Plan says 
services can safely be received 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. Our 
physician reviewer found that the medical problems are stable and there are no complex nursing or 
rehabilitation needs. Our reviewer says that the complexity of the enrollee's nursing, medical and rehabilitation 
needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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.