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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says therapy needs can be met in a lower level of care, such as in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication 
management, skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of 
therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF 
intensity is not warranted. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 20, 2020.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service wasprovided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not supported for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
requested use of Keytruda is not supported. Our physician reviewer found while the use of Keytruda for the 
enrollee's condition is supported, it is supported only for patients with no prior systemic therapy. There is no 
information regarding use of the drug as third line treatment or after previous immunotherapy such as 
Avelumab. Consequently, the drug is not medically reasonable and necessary nor safe and effective for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET scan.
You asked the Plan to pre-approve a PET scan. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says that the requested services are not medically 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 a PET scan. Our reviewer says that the
documentation supports that the requested PET scan is medically reasonable and necessary. Our physician
reviewer found the enrollee has a new diagnosis of squamous cell squamous cell of the lung. The enrollee
needs to be staged. The enrollee had a PET with CT in February 2020. Despite the PET with CT received in
February 2020, a new PET with CT is needed to stage this non-small-cell lung carcinoma. Therefore, the
enrollee meets criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a PET scan have been met. Therefore, we decided that the Plan has to preapprove
a PET scan.
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on 
September 5, 2018. 
 
You asked the Plan to pay for the drug testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says the order is not sufficiently detailed to support the intent for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the 
treating provider. 
 
In this case, the order does not indicate the specific testing to be provided. Therefore, we decided that the Plan 
does not have to pay for the presumptive and definitive drug testing provided on September 5, 2018.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for percutaneous vertebral augmentation (22513, 22515) 
provided on November 8, 2019. 
 
You asked the Plan to pay for percutaneous vertebral augmentation. You say that this was medically necessary. 
The Plan denied your request. The Plan says this is not a covered service. 
 
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 pay for percutaneous vertebral augmentation. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found percutaneous vertebral augmentation is experimental at this time. Recent peer 
review literature shows that it is not more effective than sham treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pay for percutaneous vertebral augmentation (22513, 22515) provided on 
November 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast MRI provided on March 13, 
2020. 
 
You asked the Plan to waive the copayment for the breast MRI. You say that this is a large amount of money 
for a mandatory test that you have to have because you have a history of breast cancer. You say this additional 
cost seems excessive. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $175 
copayment for each Medicare-covered advanced radiology services.  
 
You have been asked to pay a $175 copayment for the breast MRI. The breast MRI falls within the ?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 copayment for the breast MRI provided on March 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
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 medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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 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. 
 
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 you can safely receive the services you need 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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. Our physician reviewer found that your 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that you need more visits. The 
Plan denied your request. The Plan says the additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 12 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that you were authorized a reasonable 
quantity of therapy and should be able to transition to an independent home exercise program. Our reviewer 
also says that the unique skills of a professional therapist are not required to safely and effectively provide 
ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
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 medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF 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 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 long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer to LTACH are 
not met. 
 
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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short-term acute 
care hospitals. In this case, ongoing care needs include surveillance laboratory studies, wound care, tube 
feeding with oral intake advancement, and therapy services. The documentation does not support that the 
enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no required medical services identified that are available at the LTACH, that 
are not available at the current health care setting being offered by the health plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Raptor 5 3-wheeled scooter for the enrollee. 
 
You asked the Plan to pre-approve the scooter. You say that your current scooter is not meeting your needs, 
and you have fallen three times. The Plan denied your request. The Plan says this brand is not covered by the 
plan. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found there is no 
substantiation in the documentation for this specific brand of scooter. There is no documentation that the 
enrollee's needs cannot be ameliorated by a walker, cane or manual wheelchair as required by CMS 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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Raptor 5 3-wheeled scooter for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Angiography (MRA) of the neck 
(70547). 
 
You asked the Plan to pre-approve the MRA. You say that the MRA is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRA is 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 MRA. Our reviewer says that the 
MRA is not medically necessary. Our physician reviewer found the enrollee had a diagnosis of a transient 
ischemic attack. The requested study was ordered to evaluate the carotid arteries. The reviewed documentation 
does not include an exam of the carotid arteries, differential diagnosis, neurologic evaluation or other 
modalities to evaluate the arteries. Without these records, medical necessity cannot be confirmed. 
 
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 MRA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Magnetic Resonance Angiography (MRA) of the neck (70547).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuity of care with an out of network tertiary 
oncologist. 
 
You asked the Plan to pre-approve the out of network care. You say that authorization to see the requested out 
of network provider was issued in the past. You say that you want to continue care with this out of network 
provider. The Plan denied your request. The Plan says there are network providers who are able to supply the 
medical services needed. The Plan says that the enrollee does not meet the tertiary care guidelines. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees? needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 out of network care. Our reviewer 
says that the criteria for out of network coverage have not been met. Our physician reviewer found the enrollee 
has lung cancer and wishes to see an oncologist whose contract with the Plan ended on March 21, 2020. The 
records do not show that a PET scan and radiation consultation must be supplied 
 
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 out of network care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuity of care with an out of network tertiary oncologist.