Persius/hicric huggingface dataset:
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 the SNF admission. You say that the enrollee is not able to perform self-
care. The Plan denied your request. The Plan says the enrollee does not require daily skilled services. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a female, currently 
in an IRF since 9/15 after a lacunar stroke and incidental findings of squamous cell laryngeal cancer. From a 
nursing perspective, the beneficiary received enteral nutrition and medications. The beneficiary had stable vital 
signs. She had routine tracheostomy care. Regarding rehabilitation services, the beneficiary received PT, ST 
and OT in the acute hospital.   The beneficiary was at a modified independent to stand by assist level with 
functional mobility including gait to 250 feet with a rolling walker.  The beneficiary required varying assist 
with ADLs. 
 
There are identifiable skilled nursing service needs as well as skilled therapy service needs; however, these do 
not require daily skilled care. This beneficiary does not meet severity of illness or intensity of service criteria 
for 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 the SNF admission 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (CPT Code 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show safety and efficacy. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869) 
and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression 
or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the Medicare guidelines and the information about your condition, you don't 
meet all the requirements. 
 
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 system. Our reviewer says that the 
requested system is not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are on once daily insulin. There is no documentation that you are making frequent adjustments to 
your insulin dose on the basis of testing results. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 14 day system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT) 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 treatment of breast cancer is not listed as a disease site for IMRT medical necessity. 
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 therapy. Our reviewer says that the 
requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the right lung exposure of the non IMRT plan is high, and does not meet the RTOG constraints (which is 
not specific to chest wall radiation and not unexpected as lung exposure with chest wall and nodal radiation is 
generally high). However, based on the mean lung dose the non-IMRT appears to be better and there are no 
records that clearly show a better lung V20 with the IMRT plan. In fact, there is no letter of appeal from the 
radiation oncologist explaining how the dosimetric comparison supports the need for IMRT. Additionally, the 
mean heart dose is lower with the non IMRT plan. For IMRT to be medically necessary, an appreciable benefit 
must be achieved.  IMRT can be considered medically necessary when a clinically meaningful reduction in 
normal tissue dose exposure can be achieved. For this patient, there appears to be no significant improvement 
in the IMRT vs. standard plan with respect to lung or cardiac dose exposure. The IMRT plan in fact appears 
inferior. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensity-modulated radiation therapy (IMRT) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve block injections. 
 
You asked the Plan to pre-approve peripheral nerve block injections. You say that you are appealing. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because this procedure 
is considered investigational and is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that peripheral nerve blocks are not considered 
medically necessary and are not covered by Medicare at this time.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of peripheral nerve block injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve peripheral nerve block injections.
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. The Plan denied your request. The Plan says the enrollee does not 
require frequent physician visits, or intensive rehab. 
 
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 physician reviewer found 
that the enrollee was admitted for surgical treatment of a hip fracture. Her medical problems are stable. 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. There is not a reasonable expectation 
that she will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. The medical record supports a need for physical and occupational therapy, but it does not 
support a need for an intensive rehabilitation therapy program. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing home health services (G0300) provided 
February 4, 2020 to February 19, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the enrollee was seen for medical 
necessity. The type is correct. Please review for reprocessing. The Plan denied your request. The Plan says the 
claim is missing the valid HIPPS code as well as treatment authorization code. 
 
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 corrected claim is missing a HIPPS (Health Insurance Prospective Payment System) code as 
well as a valid 18 digit alphanumeric Treatment Authorization Code. Based on this information, we decided 
that Medicare rules for coverage of the skilled home health services have not been met. Therefore, we decided 
that the Plan does not have to pay for skilled nursing home health services (G0300) provided February 4, 2020 
to February 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebral augmentation of T10, T11, T12. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you had one fall in June of 2020, and symptoms since then. The fractures are older than six weeks. Also, 
the recent literature shows that kyphoplasty is not more effective than sham treatment for back pain and 
fractures. It is not likely to reduce your pain. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vertebral augmentation of T10, T11, T12.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no contraindications to alternative treatments. 
 
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 therapy. Our reviewer says that the 
requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer 
found any potential benefit or detriment of proton therapy over standard IMRT is an investigational question. 
Particularly with the use of the SpaceOAR hydrogel spacer, the risk of GI/rectal toxicity is low (since the 
rectum is pushed away from the prostate) such it is even more unlikely that there would be a potential benefit 
from proton therapy. To date, there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton 
beam therapy on clinical trials, and to not routinely offer it to patients. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breasts for 
cancer screening. 
 
You asked the Plan to pre-approve the screening breast MRI. You say that the enrollee would benefit from this 
imaging due to her family history. The Plan denied your request. The Plan says this is not covered by 
Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
This MRI is being requested in absence of signs/symptoms of breast cancer, which means that it is for 
screening purposes. Although this may be appropriate, Medicare does not cover breast MRI for screening 
alone. This breast cancer screening benefit is limited to clinical breast exams and mammography. Therefore, 
we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breasts for 
cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you 
received. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you cannot afford this 
copayment and it wasn't your choice to go to this facility. The Plan denied your request. The Plan says you 
were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment for days 1-10, a $20 copayment per day for days 11-20, and a $178 copayment per day for days 21-
100 for skilled nursing facility services.  
 
Records show that you were in the SNF , for a total of 29 
days.  As per your contract, you were not charged a copayment for the first 10 day), you were charged a copayment
of $20 per day, for a total of $180.
For the last 9 days of your stay you were charged a $178 copayment per day, for a total of $1602. Of this amount, $1662 applies to the services you received.
This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This amount applies regardless of the reason for the stay. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you have a knot that will not go down. The 
Plan denied your request. The Plan says there are in-network providers that can provide the services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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. There are insufficient records to show the 
requested services are urgent or emergent. We found no exception that would require the Plan to pre-approve 
these OON services. Therefore, we decided that the Plan does not have to pre-approve medical services to be 
provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kynmobi 30mg sublingual film. 
 
You asked the Plan to pre-approve the Kynmobi sublingual film. You say that this medication is necessary and 
should be covered. The Plan denied your request. The Plan says this oral drug cannot be covered 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 Kynmobi 30mg sublingual 
film.  
 
Benefits for the Kynmobi sublingual film 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurosurgery services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you need treatment as soon as possible to 
improve your quality of life. The Plan denied your request. The Plan says services can be obtained from an in-
network provider. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
neurosurgery services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation 
correction and anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our physician reviewer 
found it is indicated for PET CT for men with suspected prostate cancer recurrence based on elevated PSA 
after prior treatment. The criteria have not been met. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization 
imaging; skull base to mid-thigh (CPT Code 78815).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra 5% eye drops. 
 
You asked the Plan to pre-approve Xiidra 5% eye drops. You say that you say that you cannot use an off label 
product for a primary eye treatment. You also say that Xiidra is currently the only Food and Drug 
Administration approved product in the United States approved for dry eye. The Plan denied your request. The 
Plan says this drug is not covered for the enrollee'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 Xiidra 5% eye drops.  
 
Benefits for Xiidra 5% eye drops 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 interspinous spacer device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service has not been identified as generally accepted for the proposed use. 
 
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 requested services. Our physician 
reviewer found that the requested spacer is considered experimental. More research is needed to show its safety 
and efficacy. Therefore, the requested services are not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous spacer device.