Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient surgery Prostate Artery Embolization. 
 
You asked the Plan to pre-approve vascular embolization or occlusion, inclusive of all radiological supervision 
and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; 
for tumors, organ ischemia, or infarction (37243). You say that the enrollee needs this procedure. The Plan 
denied your request. The Plan says medical studies haven't proven that the procedure is helpful for treatment of 
the enrollee's health problem. 
 
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 vascular embolization or occlusion, 
inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance 
necessary to complete the intervention; for tumors, organ ischemia, or infarction (37243). Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Prostatic arterial embolization (PAE) is an experimental technique to treat symptomatic benign 
prostatic hyperplasia. Very limited international studies have demonstrated possible short-term safety and 
efficacy. The most recent American Urological Association guidelines do not recommend this procedure 
outside of a clinical trial setting. As such, the services at issue in this case are 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 vascular embolization or occlusion, inclusive of all radiological supervision and 
interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for 
tumors, organ ischemia, or infarction (37243) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve outpatient surgery Prostate Artery Embolization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair (PWC).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Austedo for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this 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 Austedo for the enrollee.  
 
Benefits for this drug 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 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 
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on 
October 29, 2020 with lethargy and aphasia due to a midbrain intraparenchymal hemorrhage. He is weak and 
deconditioned and is working with physical and occupational therapy. He is walking 35 feet with a rolling 
walker with moderate assistance and is minimum to moderate assist for transfers and activities of daily living. 
He is reportedly medically stable for discharge. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee would be better served in a slower paced, less intensive 
rehab program. 
 
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 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The 
enrollee's care needs can be met at a lower level of care. 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: Favorable

We decided that the Plan has to pre-approve Carboplatin. 
 
You asked the Plan to pre-approve Carboplatin. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has 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 pre-approve Carboplatin. Our reviewer says that the 
medication is medically necessary. Our physician reviewer found while no chemotherapy regimen has 
demonstrated improved survival or quality of life after cabazitaxel, clinical trials with carboplatin have shown 
palliative and radiographic response. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Carboplatin have been met. Therefore, we decided that the Plan has to pre-
approve Carboplatin.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313) and electronic connection (E2311). 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's upper limb function is adequate for the member to be able 
to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 these items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Provided medical 
records indicate the enrollee is independent with feeding, meal preparation, dressing and toileting with normal 
wrist and hand function and 3+/5 bilateral upper extremity strength. His upper extremity strength and function 
appear to be adequate to control the power options using their own switches. Our physician reviewer found that 
 
 
the enrollee's condition does not meet criteria for coverage of these items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller (E2377), expandable controller harness (E2313) and electronic 
connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the smoking cessation procedure provided on February 13, 
2020. 
 
You asked the Plan to pay for the smoking cessation procedure (99406). You say that the notes support the 
service. The Plan denied your request. The Plan says the records do not support the billed service. 
 
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 99406 is Smoking and tobacco use cessation counseling 
visit; intermediate, greater than 3 minutes up to 10 minutes.  
 
 
 
 
 
 
We find that CPT code 99406 is not supported in the medical record. Specifically, there is no documentation in 
the record of a plan to quit smoking, identifying triggers or learning how quitting can benefit health etc.. Based 
on this information, we decided that Medicare rules for coverage of the smoking cessation procedure (99406) 
have not been met. Therefore, we decided that the Plan does not have to pay for the smoking cessation 
procedure provided on February 13, 2020.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 based on the documentation provided, the health plan?s denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to 
perform fifteen (15) hours per week of rehabilitative services or to require regular physician evaluation. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on October 30, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
service is included in the Part A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for diagnostic imaging of retina (92134) and 
eye and medical examination for diagnosis and treatment (92012) 
 
You asked the Plan to waive the copayments for diagnostic imaging of retina and eye and medical examination 
for diagnosis and treatment. You say that you are being charged the wrong amount. The Plan denied your 
request. The Plan says the cost share is correct. 
 
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 $25 
copayment for each Medicare-covered specialist visit for Physician/Practitioner services, including doctor's 
office visits and a $25 copay for each Medicare-covered non-radiological diagnostic procedures and tests for 
Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $25 copayment for each Medicare-covered non-radiological diagnostic 
procedures and tests for diagnostic imaging of retina and eye and a $25 copayment for each Medicare-covered 
specialist visit for medical examination for diagnosis and treatment. These services fall within the 
Physician/Practitioner services, including doctor's office visits benefit category and Outpatient diagnostic tests 
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. 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 copayments for 
diagnostic imaging of retina (92134) and eye and medical examination for diagnosis and treatment (92012)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (Assays for Vitamins and Metabolic Function) 
provided. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says these types of screening services are 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. The test at issue in this appeal was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for lab services (Assays for Vitamins and Metabolic Function) provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881), 60 mg, every 2 weeks for 1 year. 
 
You asked the Plan to pre-approve Aranesp. You say that the enrollee has extremely low hemoglobin. You say 
that the enrollee already had a transfusion. You also say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the enrollee does not meet criteria for 
the coverage of Aranesp. The reviewer found that the enrollee's ferritin level indicates an iron deficiency which 
should be corrected. The reviewer found that the plan requires a trial of Retacrit which has not been attempted. 
Therefore, the reviewer found that the service is not reasonable or medically 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881), 60 mg, every 2 weeks for 1 year.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI of the brain (70551). 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because this MRI is 
needed to investigate the member's cognitive impairment. The Plan denied your request. The Plan says that the 
documentation does not show that the member has an established memory loss with impairment of activities of 
daily living. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that it is 
well within the generally accepted standards of practice and care to perform a neuroimaging study in the 
evaluation of patients with cognitive impairment and/or dementia to rule in/out any structural etiology for these 
symptoms/findings. Such a study is generally done as part of a preliminary evaluation. Our physician reviewer 
found in this setting it can otherwise be determined that the requested study would be considered to be 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
MRI of the brain (70551).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the item is necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided on January 17, 2020 through January 
31, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says A corrected claim with HIPPS MLMC codes is 
needed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Specifically, this claim was submitted with code EEEC6. Per 
Medicare, this is not an appropriate code for SNF services. Therefore, we decided that the Plan does not have 
to pay for SNF services provided on January 17, 2020 through January 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe insertion of a VeriFlex device (22869).You asked the Plan to pre-approvethe insertion of a VeriFlex device. You say that this is medically necessary.The Plan denied your request. The Plan says this is experimental.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 insertion of a VeriFlex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the 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 insertion of a VeriFlex device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe insertion of a VeriFlex device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve these services. You say that you have flat feet. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.