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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 you are now medically stable. You required moderate/maximum assistance for 
functional transfers and activities of daily living. The documentation does not support that you would be able to 
fully participate in/benefit from an intensive rehabilitation therapy program. Ongoing pain medication and 
other medication management, wound care, and daily therapy can be provided at a lower level of care. 
Therefore, you do not meet criteria for the requested admission. 
 
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: Favorable

We decided that the Plan has to pre-approve aspiration and/or injection of a large joint or joint capsule services. 
 
You asked the Plan to pre-approve aspiration and/or injection of a large joint or joint capsule services. 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 if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 aspiration and/or injection of a large 
joint or joint capsule services. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found you have a history of right hip pain. A CT 
arthrogram of the right hip demonstrated a labral tear. You have been going to physical therapy and she wishes 
to continue conservative therapy. You had an injection into the right trochanteric bursa in the past. Typical 
conservative treatment for labral tears of the shoulder and hip include rest, ice, physical therapy, anti-
inflammatory medication and injections. In this case, you have continued pain despite conservative treatment. 
Therefore, you meet criteria for the requested injection into the right hip joint. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aspiration and/or injection of a large joint or joint capsule services have been 
met. Therefore, we decided that the Plan has to pre-approve aspiration and/or injection of a large joint or joint 
capsule services.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis 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 if the clinical criteria is met, the step therapy requirements also must be 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found there was no physician 
statement or documentation to show that the patient had tried and failed Bevacizumab. There is no quality 
evidence suggesting Lucentis is superior in effectiveness or safety to bevacizumab for diabetic retinopathy. 
Current comparison studies suggest both of these drugs have a similar action, effectiveness, and safety profile. 
Bevacizumab would not likely be less effective or cause adverse effects more than the requested Lucentis. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 the patient does not require services at the proposed LTACH that are not already 
available at the current facility. Additional acute care services appear to be needed, however, considering the 
poor prognosis and request for no aggressive treatments, conservative treatments would be most appropriate 
and could be received at a lower level of care soon. There are no services available at the LTACH that are not 
already being provided and covered by the current facility. Therefore, this request for LTACH services will be 
considered not medically 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 118 miles per trip for routine 
transportation. 
 
You asked the Plan to pre-approve the additional mileage. You say that this is for a post-op visit. The Plan 
denied your request. The Plan says this requested exceeds the benefit limit. 
 
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 75 miles trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the requested addition mileage exceeds the Plan's maximum benefit for coverage of routine transportation 
mileage. Therefore, we decided that the Plan does not have to pre-approve an additional 118 miles per trip for 
routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the automated blood pressure cuff.

You asked the Plan to pre-approve the automated blood pressure cuff. You say that you are appealing the denial of the blood pressure cuff and the records provided should support the necessity of the requested item. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve the automated blood pressure cuff.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 hours of weekly personal care services (T1019). 
 
You asked the Plan to pre-approve 30 hours of weekly personal care services. You say that you need these 
services due to COVID. The Plan denied your request. The Plan says these services are not covered under your 
Medicare benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.  
 
We looked at the file and Medicare rules. The services at issue are custodial in nature. Based on this 
information, we decided that Medicare rules for coverage of 30 hours of weekly personal care services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve 30 hours of weekly personal care 
services (T1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost meal replacement shakes, Vanilla. 
 
You asked the Plan to pre-approve Boost meal replacement shakes. You say that your father is unable to chew 
and swallow food. Weight loss has become one the critical issues. The doctor recommended Boost three to four 
times a day. The Plan denied your request. The Plan says nutritional supplements taken by mouth are not 
covered under the plan benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve Boost meal replacement shakes, Vanilla.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627) to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that the seat lift is medically necessary. 
The Plan denied your request. The Plan says there is no valid physician order for the seat lift mechanism. 
Additionally, the provider requested is an out-of-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 items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Additionally, a valid physician's order is required for Durable Medical Equipment 
to be provided. Without a physician's order and medical records to support the need for the seat lift, medical 
necessity cannot be determined. Therefore, we decided that the Plan does not have to pre-approve a seat lift 
mechanism (E0627) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services for post-cataract surgery care. 
 
You asked the Plan to pre-approve the physician's services for post-cataract surgery care. You say that the 
enrollee has been an established patient since October 2017. You say that the enrollee received cataract surgery 
on November 1, 2017 and November 15, 2017 and the enrollee needs to continue this care. The Plan denied 
your request. The Plan says the enrollee must receive care from in-network providers with the exception of 
emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be 
provided with an in-network provider, which requires prior authorization from the plan.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services for post-cataract surgery care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's condition could be managed by oxygen, weight loss, exercise, or 
bronchodilators. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has not met the minimum usage requirement of at least 4 hours/night for at least 70% of nights. There is no 
documentation of the effectiveness of the device, or evidence of attempts to address the compliance issue. 
CPAP is therefore considered not 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a non-invasive ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 90 quantity of each urinary leg bag and bedside drainage bag for three month supply.
You asked the Plan to pre-approve 90 quantity of each urinary leg bag and bedside drainage bag for three month supply. You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says the requested quantity of supplies are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that normal quantities allowed are 6 urinary leg bags for 3 month supply and 6 bedside bags for 3 month supply. 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 90 quantity of each urinary leg bag and bedside drainage bag for three month supply. Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found the enrollee has history of urinary retention due to obstructive uropathy. The enrollee has a chronic indwelling urinary Foley catheter which stays in at all times with the exception of catheter changes since 2016. The enrollee is not bedridden and the enrollee ambulates with a wheeled walker and has wheelchair mobility. Normal quantities allowed are 6 urinary leg bags for 3 month supply and 6 bedside bags for 3 month supply. There is no clinical or scientific reason for the frequent bag changes. Therefore, the enrollee does not meet criteria for the requested quantity.
We looked at this physician's review, the file, and Medicare rules. We note that the plan has approved six of the requested urinary leg bag and six of the requested bedside drainage bag for three month supply. Based on this information, we decided that Medicare rules for coverage of 90 quantity of each urinary leg bag and bedside drainage bag for three month supply have not been met. Therefore, we decided that the Plan does not have to pre-approve 90 quantity of each urinary leg bag and bedside drainage bag for three month supply.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve wireless capsule endoscopy. 
 
You asked the Plan to pre-approve wireless capsule endoscopy. 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 follows Medicare rules. Medicare rules say that wireless capsule endoscopy is covered for certain 
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 wireless capsule endoscopy. Our 
reviewer says that the documentation does support that the requested services are medically reasonable and 
necessary. Our physician reviewer found the documentation shows that you have chronic intermittent 
abdominal discomfort, past history of Giardia, uterine fibroids with heavy periods, and noncompliance with 
prescribed thyroid and iron supplementation. The UGI tract was eventually evaluated but "did not show 
anything" per the documentation. Colonoscopy to the terminal ileum in May 2020 identified a diminutive 
hybrid hyperplastic sigmoid polyp, left colon diverticulosis, and hemorrhoids. The documentation shows occult 
GI bleeding, the site of which has not previously been identified by upper endoscopy, colonoscopy, radiologic 
procedures which fits under the LCD criteria of Iron deficiency anemia, which is unexplained after upper and 
lower endoscopy. Therefore, you meet 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 wireless capsule endoscopy have been met. Therefore, we decided that the Plan 
has to pre-approve wireless capsule endoscopy.  
 
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 foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are medically necessary. 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 (L3020).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient visit and consultation. You say that you would like 
reconsideration because this is a renowned hospital in the type of rare condition you have. The Plan denied 
your request. The Plan says you are enrolled in an HMO plan with no out-of-network benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve the hearing aids. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says hearing aids are not a Medicare covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids.