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

 
We decided that the Plan does not have to pre-approve Ezetimibe. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Ezetimibe.  
 
Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone excision procedure to be performed by an oral 
surgeon. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure has to be done in order 
for your dentures to fit. The Plan denied your request. The Plan says surgery for bone excision to prepare the 
mouth for dentures is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 a bone 
excision procedure to be performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have a broken leg. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (43245, 43282, C1726, C1781, C9361, J0330, J0780, J1100, J1644, J2001, J2370, J2704, J3010, J3420, J3490, J7030, J7120) provided on February 26, 2020 to February 27, 2020 by an out of network (OON) provider.

You asked the Plan to pay for OON surgical services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized and could have been provided by in-network providers.

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 has network providers available who can provide 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 surgical services (43245, 43282, C1726, C1781, C9361, J0330, J0780, J1100, J1644, J2001, J2370, J2704, J3010, J3420, J3490, J7030, J7120) provided on February 26, 2020 to February 27, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Quetiapine Fumarate. 
 
You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says this drug is 
not covered for the enrollee's condition by the Part B plan. 
 
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 Quetiapine Fumarate.  
 
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: 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 enrollee does not require the intensity of 
services provided at an IRF.  Specifically, the enrollee is not shown to be able to perform fifteen hours per 
week of rehabilitative services with regular physician evaluation.  Medicare coverage criteria are not met.  
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: 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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, 
you do not require an IRF level of care. Specifically, the records do not show you require fifteen hours per 
week of rehabilitative services and regular physician evaluation. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that home health care is medically necessary. 
The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 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 home health 
services. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the 
documentation does not support that you have an extensive decubitus ulcer, or widespread skin disorder. No 
required skilled nursing needs are identified. Medicare coverage criteria are not met. We looked at this 
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-
approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity-Modulated Radiation Therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has been enrolled in a 
national clinical trial. The Plan denied your request. The Plan says the costs in a clinical trial are covered by 
Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the requested services as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pre-approve Intensity-Modulated Radiation Therapy.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 documentation does not support the need for an intensive therapy program with 
therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 
care. Medicare coverage criteria are not met. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires slow and 
meticulous weaning, and respiratory support. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate care at the current acute care 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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital with a sore throat and sudden 
respiratory failure. He was diagnosed with a left tonsil abscess requiring intubation. He was treated with IV 
antibiotics. The course was complicated by encephalopathy, acute kidney injury, GI bleed, and new onset atrial 
fibrillation. He failed extubation recently, and is febrile requiring ongoing antibiotics and monitoring. The 
enrollee appears to still require acute care services, however is not stable for discharge. She does not require 
any services at the LTACH that are not already available at the current setting. Therefore, this request for 
LTACH services will be considered not medically necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 99190 provided on December 4, 2019. 
 
You asked the Plan to pay for CPT code 99190. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient.  
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for CPT code 99190 provided on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that manual wheelchairs are 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 a manual wheelchair. Our reviewer says 
that the documentation does not support that the requested wheelchair is medically reasonable or necessary. 
Our physician reviewer found you have a diagnosis of other abnormalities of gait mobility. While the 
documentation does indicate that you have a mobility deficit, the documentation does not reveal that this deficit 
significantly interferes with your ability to perform mobility related activities of daily living in the home. The 
documentation does not support that you have sufficient upper extremity function and other physical and 
mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a 
typical day. Therefore, you do not meet criteria for the requested wheelchair. 
 
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 manual wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a manual wheelchair.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy for skin cancer 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 that the records do not show all the needed details. 
 
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. Even though it appears that the plan had some clinical records to use in making 
their decision, the plan did not provide these records to us. There is also no evidence that the plan requested 
any additional records. Therefore, we decided that the Plan has to pre-approve radiation therapy for skin cancer 
for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a foot massage device (E1399) purchased on April 17, 2020. 
 
You asked the Plan to pay for a foot massage device. You say that this should be covered because it was 
prescribed by a doctor. The Plan denied your request. The Plan says this item is not medical in nature. 
 
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 pay for a foot massage device (E1399) purchased on April 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an increase in personal care services. 
 
You asked the Plan to pre-approve an increase in personal care services. You say that you need additional 
hours of personal care assistance. The Plan denied your request. The Plan says there does not appear to be 
medical evidence which warrants additional hours. 
 
The Plan must follow Medicare rules. The rules say custodial care is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an increase in personal care services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an increase in personal care services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the pelvis 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 are no x-rays or recent documentation of conservative therapy. 
 
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 services are not medically reasonable or necessary. Our physician reviewer found plain films of the 
SI joints would be the first imaging step in the evaluation of possible SI joint pathology. Also, serologic testing 
for the usual inflammatory markers associated with SI joint inflammation should be done prior to advanced 
imaging and such testing is not in the submitted records. 
 
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 the pelvis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a Dexcom G6 continuous glucose monitor. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that you could die without this device. 
The Plan denied your request. The Plan says the denial of authorization for this item is correct, because you are 
not currently using insulin and therefore do not meet the Medicare criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a therapeutic continuous glucose monitor is only 
covered when all 6 of the above criteria have bene 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 continuous glucose monitor. Our 
reviewer says that you do not meet the Medicare criteria for this continuous glucose monitor. Our physician 
reviewer found you are not using an insulin pump or multiple daily insulin injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous glucose monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve use of a Dexcom G6 continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you are in a wheelchair and unable to go up the 
stairs for the bathroom to shower. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need the shower chair for medical reasons. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture. 
 
You asked the Plan to pre-approve the upper partial denture. You say that the wire is broken and the dentures 
fall off when you eat. You say that you really need a new one. The Plan denied your request. The Plan says the 
denture benefit is exhausted. 
 
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, you also have a maximum benefit of 
one partial denture every 5 years. The Plan paid for a partial upper denture provided on October 27, 2015, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper 
partial denture.