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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the 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 review of the medical records, the enrollee does not meet the CMS 
coverage criteria for an IRF admission based on lack of medical and nursing needs and current functional 
status. There is no evidence of medical issues that require monitoring by an inpatient rehab physician three (3) 
times a week. The documentation does not support that there is a need for an intensive therapy program with 3 
hours a day and an interdisciplinary approach to rehab care. At CGA/ min A level with rest breaks due to 
fatigue, the enrollee neither needs acute IRF nor will they tolerate the intensity. This enrollee, does not meet the 
CMS coverage criteria for an IRF admission. The enrollee's rehab needs can be met in an alternate, less intense 
setting such as in an skilled nursing facility (SNF). 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sensors for a Freestyle Libre continuous glucose 
monitor (CGM). 
 
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 you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM and supplies are covered 
when specific criteria are met. 
 
We looked at the file and Medicare rules. The submitted documentation does not show that you meet the 
Medicare criteria for coverage of the requested therapeutic CGM and supplies. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sensors for a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy by an out-of-network provider at the 
in-network benefit. 
 
You asked the Plan to pre-approve physical therapy. You say that this physical therapy is in the same building 
you reside. You say that you are not comfortable traveling especially during the winter. The Plan denied your 
request. The Plan says services are available 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 the physical therapy at the in-network benefit. Physical therapy with the out-of-network 
provider is available through your POS benefit at the out-of-network rate. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy by an out-of-network provider at the in-network benefit.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 8, 2020. 
 
You asked the Plan to pay for laboratory services. You say that these charges are not related to hospice. You 
say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar epidural injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are covered for the above 
indications. 
 
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 injections. Our reviewer says that 
the requested injections are not medically reasonable and necessary. Our physician reviewer found that the 
member does not meet the guidelines provided for the coverage of the requested bilateral L4/L5 transforaminal 
epidural steroid injections (TFESI) every 2 weeks for 3 treatments. This is not supported as a series. There was 
no documented sustained response from prior injection to support a repeated one. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar epidural injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe acute inpatient hospital care.You asked the Plan to pre-approveacute inpatient hospital care. You say that you would like reconsideration because you are scheduled for a total knee replacement.The Plan denied your request. The Plan says it would be appropriate for you to stay overnight under observation and be admitted to inpatient if deemed necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found it would be medically appropriate to admit via observation status and the admission be changed to inpatient if deemed medically necessary at the 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 acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe acute inpatient hospital care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on May 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 13, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on May 
13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup. 
 
You asked the Plan to pre-approve the backup. You say that this is needed for electrical power problems. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
A battery backup cannot be covered by Medicare. Therefore, we decided that the Plan does not have to pre-
approve a battery backup.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pre-fabricated post and core for tooth #4. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered service per the Evidence of Coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 pre-
fabricated post and core for tooth #4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued chiropractic services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary to manage back and 
shoulder pain. The Plan denied your request. The Plan says this is not medically indicated for this medical 
condition. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 medically reasonable or necessary. Our physician reviewer found the only treatment 
allowed by Medicare for chiropractors is to treat a subluxation of the spine. The subluxation may be 
demonstrated by x-ray or by physical examination. A submitted imaging notation states CT lumbar reveals 
advanced multilevel degenerative disc disease appears similar to previous images. Central canal stenosis, at least, 
moderate, is suggested at multiple levels. This finding does not reveal a subluxation. A medical chart note reveals findings of tender lumbar paraspinals, good forward flexion, normal gait and normal lower extremity strength. Chiropractic chart notes throughout care reveal: spinal restrictions/subluxations: T3, T5, T8, T10, sacrum and left and right pelvis; pain/tenderness: lower lumbar and lumbosacral; postural analysis: short right leg (pelvic deficiency); muscle spasms: moderate lumbar, right and left calf; range of motion concerns: lumbar extension mildly reduced. These findings do not reveal evidence of subluxation per Medicare guidelines and thus, chiropractic treatment is not allowed per Medicare guidelines. 
 
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 continued chiropractic services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tolvaptan 30mg tablet 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 drug coverage is limited to Medicare Part B covered drugs. 
 
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 Tolvaptan 30mg tablet for 
the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat lift for the enrollee. 
 
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat lift for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gradient compression stockings described by code 
A6549, the transcutaneous electrical nerve stimulator (TENS) and related electrodes (E0730 and A4595), and 
the pneumatic compression device coded as E0651 provided on March 23, 2020. 
 
You asked the Plan to pay for the items provided. You say that these items are medically necessary and should 
be paid. The Plan denied your request. The Plan says the TENS unit cannot be covered due to the LCD criteria 
not being met. In addition, the compression garments are noncovered by Medicare and the compression device 
was not coded correctly by indicating whether this is a rental or purchase, and whether the item provided was 
new or used. 
 
The Plan must follow Medicare rules. The rules say that the requested items may be considered for coverage by 
Medicare when the above referenced criteria are all met.  
 
In this case, coverage cannot be provided for the A6549 compression garment as it does not fall within a 
covered benefit category. It does not meet the definition of a surgical dressing. In addition, the TENS unit and 
related supplies are noncovered as there is no evidence of participation in a clinical trial, which is required for 
use of this item for low back pain. Finally, the pneumatic compression device was not coded with a modifier to 
indicate rental vs purchase, nor was any information received showing whether the item was new or used. 
Based on all this information, we find that the rules for coverage of these items have not been met. Therefore, 
we decided that the Plan does not have to pay for the gradient compression stockings described by code A6549, 
the transcutaneous electrical nerve stimulator (TENS) and related electrodes (E0730 and A4595), and the 
pneumatic compression device coded as E0651 provided on March 23, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI of the knee, hip, or ankle for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no documented exam, no plain imaging, and no conservative management 
documented. 
 
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 the 
requested MRI is medically reasonable and necessary. Our physician reviewer found the presence of such a 
large mass in the popliteal fossa is most likely due to a dissecting popliteal cyst. A hematoma could be 
considered along with soft tissue neoplasms including Malignant Fibrous Histiocytoma and less likely 
liposarcoma.  In order to further clarify the mass MRI imaging including IV contrast enhancement would be 
the next procedure of choice.  If there are elements of enhancement within the mass neoplastic process would 
have to be excluded. If areas of hemosiderin were to be found hematoma would be more likely. In any case the 
presence of such a mass on ultrasound provides a valid indication for MRI and the requested exam should be 
approved. 
 
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 knee, hip, or ankle 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 the Vertiflex Superion interspinous spacer device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the health plan guidelines are not met. 
 
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 device. Our reviewer says that the 
requested device is 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion interspinous spacer device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional miles. You say that  The Plan denied your request. The Plan 
says the service is a covered benefit, but the request will exceed the benefit limits set in the agreement for 
routine transportation. 
 
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 50 miles one-way per trip. 
 
We looked at your request, the records in the case file, and the rules. You are requesting a trip of 149 miles. 
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 miles.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to approve an inpatient admission for percutaneous nephrostolithotomy or 
pyelostolithotomy. 
 
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says that the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 approve acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee has a history of multiple complex medical problems, including that of strep A 
sepsis leading to loss of all four extremities in the past. She has high risk indications that makes it medically 
appropriate that she require inpatient hospital stay given that the procedure that is to undergo carries risk of 
infection, pneumothorax and bleeding. It is reasonable and medically necessary to monitor the enrollee as 
inpatient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to approve an inpatient admission for percutaneous nephrostolithotomy or pyelostolithotomy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bubble echocardiogram to be provided by the requested facility.

You asked the Plan to pre-approve the bubble echocardiogram. 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 contract with the Plan also 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.

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 for bubble echocardiogram to be provided by the requested facility.