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

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head or brain 
(70450) and transthoracic echocardiography (93306). 
 
You asked the Plan to pre-approve these services. You say that a CT scan of the head and transthoracic 
echocardiography are medically necessary for the enrollee. The Plan denied your request. The Plan says the 
requested services are not medically necessary for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 these services. Our reviewer says that a 
CT scan of the head and transthoracic echocardiography are not medically necessary. Our physician reviewer 
found that the patient is chronically ill with multiple medical problems. A CT scan was ordered due to 
Hyponatremia. However, Hyponatremia is not an indication for a CT scan of the head. Additionally, an 
indication could not be found for an echocardiogram. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the head or brain (70450) and transthoracic 
echocardiography (93306).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of bilateral breasts 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 there is no direct family history of breast cancer - only paternal aunt. 
 
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 not medically reasonable or necessary. Our physician reviewer found the enrollee has no 
symptoms and no first degree relative with a history of breast cancer. Her lifetime risk for breast cancer using 
the accepted Tyrer-Cuzick model is 4%. Her mammogram of 8/22/20 showed heterogeneously dense tissue but 
no abnormality. Recommendation was described as annual mammography. This MRI request is patient-driven, 
per the records submitted. Screening breast MRI is indicated when there is a greater than 20% lifetime risk of 
breast cancer or if there is a genetic predisposition for breast cancer due to a documented genetic trait.  Also, 
MRI may be used if there is equivocal mammography finding or if the breast tissue on mammography is 
Extremely Dense. None of these criteria applies. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of bilateral breasts for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Retacrit is only 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 Retacrit. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a pretreatment erythropoietin level of 1063. Due to the elevation in the 
erythopoietin level the use of Retacrit is unlikely to be of benefit in this enrollee. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve avelumab (Bavencio). 
 
You asked the Plan to pre-approve Bavencio. The Plan denied your request. The Plan says the drug is only 
covered for metastatic Merkel cell carcinoma. 
 
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 Bavencio. Our physician reviewer 
found that Bavencio has been requested to treat stage IIB Merkel cell cancer of the humerus after radiation. 
Avelumab is approved and supported only for metastatic Merkel cell cancer. The enrollee does not have 
metastatic disease. The requested use is not FDA approved. The requested use is not supported in any of the 
CMS approved compendia. The use is not listed as not indicated, not supported or not recommended in any of 
the compendia. The documentation does not support that the requested drug is safe and effective, and otherwise 
reasonable and necessary for this 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 Bavencio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve avelumab (Bavencio).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable walk-in whirlpool tub.

You asked the Plan to pre-approve the requested tub. You say that care is difficult due to spasticity and contractions. The Plan denied your request. The Plan says this equipment is not providing a medical purpose.

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 portable walk-in whirlpool tub.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty hospital bed.

You asked the Plan to pre-approve the bed. 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. Medicare rules say that a heavy-duty hospital bed is covered for enrollees between 350 to 600 pounds.

The enrollee's weight is 221 pounds. This not within the covered range for this bed. Based on this information, we decided that Medicare rules for coverage of the bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty hospital bed.
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 require fifteen 
(15) hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing services provided by a 
participating provider on February 1, 2020, to February 28, 2020. 
 
You asked the Plan to waive the copayment for a skilled nursing services. You say that this is a massive 
financial burden. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment per day for days 1-20 and a $178 copayment per day for days 21-100 for skilled nursing facility 
(SNF) care.  
 
You have been asked to pay a $0 copayment per day for days 1-20 and a $178 copayment per day for days 21-
43 for a skilled nursing services. You have been asked to pay a total of $3,981.26. A skilled nursing services 
falls within the skilled nursing facility (SNF) care 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 a skilled nursing services provided by a participating provider on February 1, 2020, to February 
28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical conditions are stable. 
 
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 do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. Your care 
needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the entire amount for the extractions and dentures. 
 
You asked the Plan to pre-approve the entire amount for the dental services. You say that you have 9 teeth that 
were ruined from previous radiation. You say that you have need those teeth pulled with anesthesia. You also 
say that since you need to have dentures made, you do not have any additional money to pay for the 9 teeth that 
need to be removed. The Plan denied your request. The Plan says there is a $1,000 allowance for covered 
dental services. The Plan also says that you are responsible for 100% of the charges beyond the $1,000 
allowance. 
 
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, there is an annual allowance of $1,000. 
Any services that exceed that limit are your responsibility. Therefore, we decided that the Plan does not have to 
pre-approve the entire amount for the extractions and dentures.
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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for atrial fibrillation with rapid ventricular response and acute on chronic heart failure. The patient 
was discharged home on October 23, 2020. The patient has poor appetite and has had multiple falls at home. 
Medical problems are stable. There are no identified problems that need inpatient medical management. There 
are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The 
medical record supports a need for physical and occupational therapy but it does not support a need for an 
intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Bioimpedance Spectroscopy-- extracellular fluid analysis for 
lymphedema assessment (CPT Code 93702). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the services are not 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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found patient with high risk for lymphedema.  Bioimpedence spectroscopy is indicated in this case 
given this patient is at high risk of this common complication. Our physician reviewer agrees with the position 
of the ordering Provider. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Bioimpedance Spectroscopy-- extracellular fluid analysis for lymphedema assessment (CPT Code 
93702).  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the requested provider is an advanced 
congestive heart failure specialist. The Plan denied your request. The Plan says the requested services are 
available within the plan 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
cardiology 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 pay for the prolonged evaluation and management service (99358) 
provided on May 5, 2020. 
 
You asked the Plan to pay for the prolonged evaluation and management service. You say that you would like 
reconsideration because a prolonged service was rendered via telephone. The Plan denied your request. The 
Plan says this code is only appropriate after face-to-face contact. 
 
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 99358 is prolonged evaluation and management service 
before and/or after direct patient care; first hour. The rules also say that the provider, supplier, or beneficiary, 
as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment 
is due and the amount of payment. 
 
We find that CPT code 99358 is not supported in the record. Specifically, the record is not clear regarding 
whether an appropriate audio-only code was billed. Of note, the record indicates that an audio-only code was 
billed for this date of service, but it is unclear if this is a separate service or a corrected claim for the same 
service. 

Based on this information, we decided that Medicare rules for coverage of the prolonged evaluation and 
management service have not been met. Therefore, we decided that the Plan does not have to pay for the 
prolonged evaluation and management service (99358) provided on May 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy, sclerotherapy procedure. 
 
You asked the Plan to pre-approve the endovenous ablation therapy, sclerotherapy procedure. 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 
endovenous ablation therapy, sclerotherapy procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay was 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the medical record is reviewed in its entirety.  
The member has stabilized medically and has been making slow progress with therapy at an inpatient 
rehabilitation facility. The member does continue to require skilled therapy services on a daily basis. There is 
no documentation to support that the member can no longer receive skilled rehab at the IRF level of care. There 
is no documentation to support that there is care available at the SNF that is not available at the inpatient 
rehabilitation facility (IRF). The member does not have any parental medication; complex wound care or 
nutrition given via a feeding tube. The member is medically stable without any acute exacerbations of chronic 
medical problems. The member continues to require inpatient rehab services to improve strength and function. 

Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.