Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Speech Therapy services (92507). 
 
You asked the Plan to pre-approve the Speech Therapy services. You say that the Speech Therapy services are 
medically necessary. The Plan denied your request. The Plan says these services are not considered skilled and 
therefore are not covered. 
 
 
 
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 Speech Therapy services. 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 the records do not show that skilled speech therapy is 
needed to effectively provide treatment, care, and/or services in order to improve the patient's level of function, 
or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent 
deterioration. The patient's functional level does not require skilled speech therapy. 
 
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 Speech Therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Speech Therapy services (92507).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four removals of an impacted tooth (D7240 x4). 
 
You asked the Plan to pre-approve the removals of an impacted tooth. You say that the prior authorization 
should have been approved because you are in pain. The Plan denied your request. The Plan says this service is 
not covered under your benefit package. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four 
removals of an impacted tooth (D7240 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a footplate (K0040), seat belt (E0978), anti-tip (E0978) 
and battery charger (E2366). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says these components 
are not denied but are included in the base allowance for the K0823. 
 
The Plan follows Medicare rules. Medicare rules say that a Column II code is included in the allowance for the 
corresponding Column I code when provided at the same time. 
 
The file shows that the requested accessories are included in the base allowance for the approved wheelchair 
and should not be billed separately.. This means that Medicare rules for coverage of the wheelchair accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a footplate (K0040), seat 
belt (E0978), anti-tip (E0978) and battery charger (E2366).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on December 1, 2018. 
 
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 procedure code 99292 is not supported. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the add-on code was not 
billed with a required primary procedure code. 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 pay for the 
critical care services rendered on December 1, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a knee orthosis (L1843) 
 
You asked the Plan to preapprove the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the request is not medically necessary because your records show you do not have recent 
injury or surgery or objective evidence of instability. 
 
The Plan must follow Medicare rules. Medicare rules say that knee orthoses defined by code L1843 are 
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s) or when knee 
instability is documented by examination of the beneficiary and objective description of joint laxity. The record 
sent by the provider indicates knee pain but the records do not demonstrate recent injury or surgery or that 
instability of the knee was found on physical exam. Therefore, we decided that the Plan does not have to 
preapprove a knee orthosis (L1843)
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that you are making 
phenomenal progress and would like to continue therapy. The Plan denied your request. The Plan says 
additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 8 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that you have had extensive therapy for this condition 
and are participating in an independent exercise program. Our reviewer says that the unique skills of a 
professional therapist are not required to safely and effectively provide ongoing treatment. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cardiomems system for the enrollee. 
 
You asked the Plan to pre-approve a Cardiomems system. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that this service is considered experimental and 
investigational. 
 
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 a Cardiomems system. Our reviewer 
says that a Cardiomems system is not considered medically reasonable and necessary in this case. 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. Moreover, concerns 
have been raised about potential bias in this trial calling into question the results. Therefore, 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. Our physician reviewer found that Medicare coverage criteria are 
not met since the device should still be considered experimental or 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 a Cardiomems system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Cardiomems system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections to treat pyloric stenosis. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee's condition is not indicated for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that Botulinum toxins are only covered under certain 
medical 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 the requested services. Our physician 
reviewer found that the enrollee has hypertrophic pyloric stenosis. The enrollee does not have an indication 
covered for the requested treatment. Based on the rules and records provided, the requested injection is not 
medically reasonable or necessary to treat the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Botox injections to treat pyloric stenosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) and accessories (A7027, A7028, A7030). 
 
You asked the Plan to pre-approve a CPAP device and accessories. You say that you need these items. The 
Plan denied your request. The Plan says you already have a CPAP device. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a CPAP device. Therefore, we decided that the Plan does not have to pre-approve 
a continuous positive airway pressure (CPAP) device (E0601) and accessories (A7027, A7028, A7030).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has acute deterioration and would thrive 
best at an IRF. The Plan denied your request. The Plan says the denial of authorization for IRF service is 
correct. 
 
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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. The records support a need for physical and occupational therapy, 
but do not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-one (J7326). 
 
You asked the Plan to pre-approve Gel-one. The Plan denied your request. The Plan says the use of Gel-one 
does not meet medical necessity. The Plan also says that it is unknown if there has been a trial and failure of 
non-drug therapy, non-steroidal anti-inflammatory drugs before using Gel-One. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Gel-one. Our reviewer says that Gel-
one is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
documentation shows that the enrollee has trialed ice, muscle relaxers and one steroid injection. Our reviewer 
found that there is no discussion of other oral medications, physical therapy, splinting, or other conservative 
treatments. Our reviewer also found that without the documentation of a trial or contraindication to these 
treatments, medical necessity for the requested Gel-One cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one (J7326).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) brain imaging 
(78608). 
 
You asked the Plan to pre-approve PET Scan. You say that you are attaching the enrollee's medical record for 
review and reconsideration of the denial. The Plan denied your request. The Plan says the records do not 
support that the enrollee meets the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PET Scan. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the records provided for review did not suggest that the member met diagnostic 
criteria for both AD and FTD. Rather, the records did not readily support the presence of either diagnosis. 
Furthermore, there were other potential causative factors present that could explain the enrollee's memory 
problems (notably her history of excessive alcohol use).  In this context, the initial requirements set forth in the 
NCD would not have been satisfied in this case. In as much the proposed study would not have met Medicare 
criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET Scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve positron emission tomography (PET) brain imaging (78608).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM) and sensors. 
 
You asked the Plan to pre-approve the CGM and sensors. You say that the requested items are medically 
necessary because you do not have fingers or hands. You say that you cannot use the requested CGM without 
the sensors. The Plan denied your request. The Plan says that there is no evidence that the enrollee has been 
using this device for the past five years. The Plan say that there is no evidence that the current CGM is lost or 
damaged beyond repair. 
 
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. Specifically, the Plan did not provide any medical records. The Plan did not 
show any evidence of having made reasonable attempts to obtain medical records. Without this necessary 
documentation, we are unable to determine whether the Plan?s denial reason is valid. There is no evidence of 
when the enrollee previously got a CGM, nor is there evidence that a replacement CGM is not medically 
necessary. The Plan did not address the medical necessity of the requested sensors. The Plan has not 
substantiated their denial reason or shown that coverage criteria have not been met. Therefore, we decided that 
the Plan has to pre-approve a continuous glucose monitor (CGM) and sensors.  
 
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 pay for chiropractic services provided on May 29, 2020. 
 
You asked the Plan to pay for the chiropractic services. 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 
chiropractic services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for chiropractic services provided on May 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RUXIENCE for the enrollee. 
 
You asked the Plan to pre-approve RUXIENCE. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that this is not indicated for the treatment of unspecified complication 
of lung transplant, and lung transplant rejection. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 RUXIENCE. Our reviewer says that 
RUXIENCE is not medically reasonable and necessary for the enrollee in this case. The enrollee underwent a 
lung transplant and the requested medication is requested for the treatment of rejection. Review of compendia 
does not support the use of Rituximab for the treatment of the enrollee's condition. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for coverage of RUXIENCE. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RUXIENCE have not been met. Therefore, we decided that the Plan does not 
have to pre-approve RUXIENCE for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient care provided from July 13, 2019, to July 17, 2019. 
 
You asked the Plan to pay for inpatient care. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the readmission was caused by a premature discharge. 
 
The Plan follows Medicare rules. Medicare rules say that early readmission cases must be reviewed to 
determine if the previous inpatient hospital services and the post-hospital services met professionally 
recognized standards of health care. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient care. Our reviewer says that these 
hospital services were not the result of a premature discharge. Our physician reviewer found review of records 
support the enrollee was admitted on June 27, 2019, for hypertensive urgency requiring a continuous infusion 
and intensive care unit admission.  The enrollee was discharge on July 1, 2019.  The enrollee was treated for 
hypertensive urgency and her transition to oral medications with satisfactory vital signs at the time of 
discharge.  Recurrence of a similar chief complaint two weeks later was not a reasonable, avoidable 
expectation at the time of discharge. The inpatient care starting on July 13, 2019, was a new presentation and 
the need for admission need supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have been met. Therefore, we decided that the Plan has to pay for 
inpatient care provided from July 13, 2019, to July 17, 2019.  
 
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 pay for physician's services provided on July 8, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on July 8, 2020.