Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for contact lenses provided on September 26, 2019. 
 
You asked the Plan to pay for eyewear. You say that these contact lenses are not a luxury; they are a necessity 
for you because without them you are unable to see. The Plan denied your request. The Plan says that the 
denial of payment for this eyewear is correct, because these contact lenses are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit a copy of the applicable Evidence of Coverage (EOC) 
for this date of service. Without this documentation, we cannot determine whether your contract with the Plan 
includes any supplemental vision benefits which may cover these contact lenses. Therefore, the Plan has not 
shown that its decision to deny payment is correct or justified according to the health plan contract. Therefore, 
we decided that the Plan has to pay for contact lenses provided on September 26, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 20, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on November 20, 2019.
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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a home ventilator provided on February 8, 2020 and 
February 9, 2020. 
 
You asked the Plan to pay for the home ventilator. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
home ventilator. We found no exception that would require the Plan to pay for this item. Therefore, we decided 
that the Plan does not have to pay for a home ventilator provided on February 8, 2020 and February 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 28, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services should be paid at the Original 
Medicare rate. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on February 28, 
2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says there are 
contract facilities within distance requirements. 
 
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 skilled 
nursing facility (SNF) services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
September 3, 2020. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee would benefit from continued 
daily skilled therapy to help work past her plateau. The Plan denied your request. The Plan says no further 
improvement is expected and daily skilled services not required to prevent deterioration of the enrollee's 
condition. 
 
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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is an 81-year-old 
woman with a history of stroke, atrial fibrillation, and hypertension, who suffered a fracture of her left pubis. 
As of 8/20/20, the enrollee was requiring the assist of 2 staff members per Hoyer lift for transfers. Assistance is 
required for ADLs. Staff propels the enrollee in a wheelchair. 
 
No required skilled nursing services are identified. The enrollee may benefit from continued therapy services; 
however, the documentation does not support that skilled services are medically reasonable and necessary for 
this enrollee on a daily basis in an SNF. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care beyond September 3, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs this device due to her 
worsening heart failure. The Plan denied your request. The Plan says there are not enough studies to show the 
device consistently improves the enrollee's condition. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of hyperlipidemia, hypertension, COPD, obesity, sleep apnea, 
atrial fibrillation and NYSHA Class III congestive heart failure with preserved LV ejection fraction (LVEF 
55%), requiring hospitalization. In this circumstance therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to 
standard medical therapy.  Concerns have been raised about potential bias in this trial calling into question the 
results. The efficacy of the CardioMEMS device is uncertain at this time according to leading authorities, and 
not recommended in current guidelines for the treatment of heart failure. Therefore, the device is still 
considered experimental/investigational. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 physical therapy visits.

You asked the Plan to pre-approve the requested visits. You say that you are not making progress, and have no range of motion. The Plan denied your request. The Plan says you are independent with a home exercise program.

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 the requested visits. Our physician reviewer found that you underwent a menisectomy on your right knee. 30 therapy sessions were previously approved. It is noted on August 17, 2020, that you noticed an overall improvement in general mobility of the right knee, although the progress slowed down considerably. You had had 4-/5 strength with flexion and extension of the right knee. You were ambulating with a moderately antalgic gait. The documentation does not support that the unique skills of a professional therapist are required for continued 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 the requested visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crown lengthening for teeth #18 and 19. 
 
You asked the Plan to pre-approve crown lengthening. You say that the procedure is medically necessary and 
very expensive. The Plan denied your request. The Plan says the service is not covered. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental 
crown lengthening for teeth #18 and 19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you had a stroke and need the PWC to regain 
function. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC is covered when specific criteria 
are 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 these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records do not contain 
any documentation that you have a mobility limitation that significantly impairs your ability to participate in 
one or more mobility-related activities of daily living (MRADLs). The requested PWC is therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto. 
 
You asked the Plan to pre-approve Entresto. 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 a covered benefit. 
 
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 Entresto.  
 
Benefits for Entresto 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that the enrollee has no other form of 
transportation. The Plan denied your request. The Plan says the enrollee can have their total of 24 trips, but the 
benefit cannot be added to. 
 
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 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that the enrollee has used 
23 one-way trips. Once the enrollee has used 24 one-way trips, she will have exhausted the Plan maximum 
benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (CPT Code 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says medical studies have not proven that the device is helpful for treatment of 
the enrollee's health problem. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device remains experimental for use in spinal surgery. More research is needed to show the 
safety and efficacy of the device. It is not needed in this case. There is no spinal instability documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869) 
and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression 
or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870).
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 medical records provided 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. Based on the medical records provided 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy sessions. 
 
You asked the Plan to pre-approve physical therapy sessions. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are 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 physical therapy sessions. 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 based on the medical records provided there is no 
documentation that the additional requested therapy is generally accepted as specific and effective therapy for 
the patient?s condition. There is no documentation that the patient's condition has significantly improved with 
the thirty treatments already provided. Based on the medical records provided there is no documentation that 
the unique skills of a professional therapist are required to safely and effectively provide the additional 
treatment, that the services can be safely and effectively performed only by a therapist or under the supervision 
of a therapist. There is no documentation that the patient's condition has significantly improved with the thirty 
treatments already provided. Based on the medical records provided there is no documentation that the 
specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver 
a program to maintain the patient's current condition or to prevent or slow further deterioration. There is no 
documentation that the patient's condition has significantly improved with the thirty treatments already 
provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ten (10) additional physical therapy sessions.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Depo-testosterone. 
 
You asked the Plan to pre-approve the requested drug. You say that the enrollee has been educated on how to 
self-administer the drug. The Plan denied your request. The Plan says drugs that are usually filled by the 
pharmacy are not covered through the medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the 
medication does not represent an expense to the physician and will not be included in the physician's bill, it is 
not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Depo-
testosterone.  
 
Benefits for the requested drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ztlido patches. 
 
You asked the Plan to pre-approve Ztlido. You say that the enrollee has tried non-opioid treatments. The Plan 
denied your request. The Plan says Ztlido to be administered at home is not covered under the Part B benefit. 
 
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 Ztlido patches.