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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says that ongoing skilled services can be provided at a lower 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardiology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the cardiology services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says that there are equally qualified in-network cardiology specialists 
available to you that can provide the care and treatment you are requesting. 
 
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 cardiology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that these items are medically necessary. The 
Plan denied your request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above 
criteria have been met. 
 
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or 
more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met.  
 
 
 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor 
(CGM) and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says care can be safely received in another setting, such as a skilled nursing
facility.
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 intravenous antibiotics, hemodialysis, surveillance
laboratory studies, decubitus ulcer care, 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent (J3590).
You asked the Plan to pre-approve Praluent. You say that the enrollee has seen improvement with her cholesterol using Praluent. You also say that the enrollee should continue using Praluent for her health. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent (J3590).
Benefits for Praluent may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton beam therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not indicate that the staging of this cancer is appropriate for proton beam 
therapy. 
 
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 therapy. Our reviewer says that the 
requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the need for proton therapy for advanced lung cancer needs to be established an on individual basis with 
a plausible rationale as to why proton therapy is needed in lieu of more standard 3D conformal radiation or 
IMRT. Based upon the provided records it is not plausible that proton therapy would provide a clinically 
meaningful benefit over a well-designed IMRT plan. Its potential benefit over non-proton-based radiation is an 
investigational question. Thus, proton therapy is not necessary as it would not meet ASTRO or NCCN criteria 
and therefore would not be ?when used for routine cases - furnished in accordance with accepted standards 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 the therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the jaw reconstruction, implant removal and moderate sedation.
You asked the Plan to pre-approve the jaw reconstruction, implant removal and moderate sedation. You say that an implant was put in incorrectly causing a bone to be exposed and an infection. You say that the infection is getting worse and the implant is causing bone damage. The Plan denied your request. The Plan says the services are not covered by Medicare or your plan.
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. The Plan covers the jaw reconstruction, implant removal and moderate sedation when the services are medically necessary and reasonable. 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 jaw reconstruction, implant removal and moderate sedation. Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found that the removal of the failed implant is considered a dental issue as it relates to the jaw, teeth and supporting structures. Our reviewer says that the Plan provisions specifically excludes coverage for treatment of these issues if related to the structures that support the teeth. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the jaw reconstruction, implant removal and moderate sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve the jaw reconstruction, implant removal and moderate sedation.
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 need more rehab to regain mobility. 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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do not require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methylenetetrahydrofolate reductase (MTHFR) gene 
testing. 
 
You asked the Plan to pre-approve the MTHFR gene testing. You say that it is felt that this testing is medically 
necessary. The Plan denied your request. The Plan says the Factor V Leiden and Factor II prothrombin tests 
were approved; however, there is no coverage for MTHFR gene testing. 
 
The Plan must follow Medicare rules. Medicare rules say that MTHFR gene testing is not covered by Medicare 
as there is broad consensus of a lack of clinical utility of the results. Therefore, we decided that the Plan does 
not have to pre-approve methylenetetrahydrofolate reductase (MTHFR) gene testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the Prolia. You say that Prolia is medically necessary for treatment of the 
enrollee's osteoporosis. The Plan denied your request. The Plan says the enrollee has not met the guidelines for 
coverage because bisphosphonate has not been tried first. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee is noted to have 
osteoporosis.  A request has been made for Prolia to treat the osteoporosis.  The health plan requires that other 
forms of osteoporosis medications be used.  There is no evidence that the enrollee is allergic to or intolerant of 
these other forms of medication.  There is no evidence that the enrollee has tried and not responded to these 
other forms of medication.  There is no documentation as to why these other forms of medication would not be 
expected to be safe and effective for the enrollee.  Therefore, the requested Prolia is not shown to be currently 
medically necessary and reasonable. 
 
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 Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says a trial of physical therapy is required. 
 
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 injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records indicate that you have declined physical therapy. Documentation of a trial of physical therapy 
was not provided. This is not medically reasonable or necessary for you. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair,
patient weight capacity up to and including 300 pounds (K0823), Power wheelchair accessory, u-1 sealed lead
acid battery, each (e.g., gel cell, absorbed glassmat) (E2365) and wheelchair accessory, adjustable height,
detachable armrest, complete assembly, each (E0973).
You asked the Plan to pre-approve the DME. You say that the authorization was submitted before you had the
removal of your right leg from above the knee. You state you need this power chair to be able to get around.
The Plan denied your request. The Plan says the Medicare rules have not been met.
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 DME. Our physician reviewer
found the documentation supports that you have sufficient upper extremity function to propel a manual
wheelchair in the home to participate in MRADLs during a typical day.
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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including
300 pounds (K0823), Power wheelchair accessory, u-1 sealed lead acid battery, each (e.g., gel cell, absorbed
glassmat) (E2365) and wheelchair accessory, adjustable height, detachable armrest, complete assembly, each
(E0973).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve attendant care services (S5125). 
 
You asked the Plan to pre-approve attendant care services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says these services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.  
 
We looked at the file and Medicare rules. The record shows that the requested services are for help with 
activities of daily living and are custodial in nature. Based on this information, we decided that Medicare rules 
for coverage of attendant care services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve attendant care services (S5125).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that because of your medical condition you 
need a  power wheelchair. The Plan denied your request. The Plan says there is no information provided that 
your home has adequate space to use a power wheelchair. 
 
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.  
 
The file does not show that you can safely operate the PMD being requested in your home. There is no Home 
Assessment documentation. This means that Medicare rules for coverage of a PMD have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasound to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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/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 
an ultrasound to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medic alert bracelet. 
 
You asked the Plan to pre-approve a medic alert bracelet. You say that a medic alert bracelet would be 
beneficial for help in the event of a fall. The Plan denied your request. The Plan says a medic alert bracelet is 
an emergency communication device and does not serve a diagnostic or therapeutic purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
A medic alert system is an emergency communications system which does not serve a diagnostic or therapeutic 
purpose and is excluded from coverage by Medicare. Therefore, we decided that the Plan does not have to pre-
approve a medic alert bracelet.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner and seat lift mechanism.
You asked the Plan to pre-approve the recliner and seat lift mechanism. You say that you would like reconsideration because you need the recliner to improve your daily life and ability to move to and from the wheelchair without complication. The Plan denied your request. The Plan says a replacement recliner is not medical in nature and you do not meet the LCD criteria for coverage of the seat lift mechanism.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The recliner 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. Additionally, the record does not show that you have severe arthritis of the hip, that the seat lift mechanism is a part of the treating practitioner's course of treatment, that you are completely incapable of standing up from a chair or that you have the ability to ambulate once standing. You do not meet LCD criteria for coverage of the seat lift mechanism. Therefore, we decided that the Plan does not have to pre-approve a recliner and seat lift mechanism.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5/F2/MTHFR gene analysis. 
 
You asked the Plan to pre-approve the testing. You say that this should be paid for. The Plan denied your 
request. The Plan says this request is not medically necessary, because there is no indication that you are 
pregnant. 
 
The Plan must follow Medicare rules. Medicare rules say that MTHFR testing is only covered for pregnant 
patients. 
 
You do not qualify for this testing. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve F5/F2/MTHFR 
gene analysis.