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

 
We decided that the Plan does not have to pre-approve a Progensa PCA3 assay. 
 
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 the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of other 
general symptoms and signs. Lower urinary tract symptoms are reported. A prostate specific antigen (PSA) on 
June 29, 2020 is reported to be 4.87. The PCA3 Score is intended to be used in conjunction with PSA and other 
risk indicators to guide appropriate patient management in the "at risk" population of men who have had one or 
more previous negative prostate biopsies and for whom a repeat biopsy would be recommended based on 
current standard of care. The documentation does not support that the enrollee has had one or more previous 
negative prostate biopsies. The documentation does not support that the requested testing improves the 
management and outcome of patients with elevated PSA. 
 
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 Progensa PCA3 assay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that you need to check your insulin 
levels at least 6 times per day. The Plan denied your request. The Plan says the denial of authorization for this 
item is correct, because you only take insulin once per day. 
 
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 use of the requested continuous glucose monitor. 
Our physician reviewer found there is no documentation that you are insulin-treated with multiply daily 
injections of insulin or using a continuous subcutaneous insulin infusion pump. 
 
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 a Freestyle Libre continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve left and right orthoses. 
 
You asked the Plan to pre-approve Left and Right: Ankle foot orthosis, plastic or other material, custom 
fabricated (L1940), Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis 
only (L2330),  Addition to lower extremity orthosis, soft interface for molded plastic, below knee section 
(L2820). You say that the enrollee meets Medicare requirements for the orthoses. The Plan denied your 
request. The Plan says that the orthoses are not supported in the medical records received. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Left and Right: Ankle foot orthosis, 
plastic or other material, custom fabricated (L1940), Addition to lower extremity, lacer molded to patient 
model, for custom fabricated orthosis only (L2330),  Addition to lower extremity orthosis, soft interface for 
molded plastic, below knee section (L2820). Our reviewer says that the requested items/services are considered 
medically reasonable and necessary in this case. Our physician reviewer found the medical documentation does 
meet the requirements for coverage of custom ankle foot orthoses for this enrollee. The medical documentation 
dated May 20,2020 advises that this enrollee requires foot and ankle stabilization for medical reasons. The 
medical documentation advises that this enrollee demonstrates foot and ankle weakness with reduced range of 
motion to foot and ankle joints. The medical documentation also advises that this enrollee does indeed have the 
potential to benefit functionally, allowing for reduced fall risk and ability to ambulate without pain. Therefore, 
the custom ankle foot orthoses are indeed medically reasonable and necessary in the medical documentation 
does support 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 Left and Right: Ankle foot orthosis, plastic or other material, custom fabricated 
(L1940), Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only 
(L2330),  Addition to lower extremity orthosis, soft interface for molded plastic, below knee section (L2820) 
have been met. Therefore, we decided that the Plan has to pre-approve left and right orthoses.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unspecified preventive procedure (D1999), impacted 
tooth removal (D7240), consultation (D9310) and therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve the unspecified preventive procedure (D1999), impacted tooth removal 
(D7240), consultation (D9310) and therapeutic parenteral drugs (D9612). You say that your wisdom teeth are 
causing you a lot of pain and discomfort. You say that medication isn't helping, and you need help. The Plan 
denied your request. The Plan says the services are not covered benefits. 
 
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 the 
unspecified preventive procedure (D1999), impacted tooth removal (D7240), consultation (D9310) and 
therapeutic parenteral drugs (D9612).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography, (CT) scan, thorax without dye 
(71250). 
 
You asked the Plan to pre-approve the CT scan. You say that your doctor says that you need to do a CT scan 
for clear examination view. The Plan denied your request. The Plan says this request is not medically necessary 
per Medicare guidelines at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this enrollee has chest pain and chronic cough since February.  A pulmonary nodule, 3mm 
in diameter was noted on a CT of the chest 11/20/14 unchanged since 2007.  Based upon no change in 7 years 
that nodule would be considered benign per guidelines and follow-up CT would not be 
indicated.  Enrollee had a chest x-ray on 7/20/20 which described improvement since prior exam.  The 
requested CT of the chest had as an indication to follow the 3mm nodule described and as such is not medically 
necessary.  The enrollee's smoking history is unknown and thus it cannot be determined if he qualifies for low 
dose lung CT.  Also, the request has not been made due to the enrollee's chest pain and cough.  In summary, 
the requested CT of the chest to follow a 3 mm pulmonary nodule previously described as unchanged between 
2007 and 2014 is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography, (CT) scan, thorax without dye (71250).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that skilled nursing will help you become more 
mobile and independent. The Plan denied your request. The Plan says you have no skilled nursing needs, are 
not able to participate in therapy services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, you 
received oral medications, and had stable vital signs. There are no identifiable skilled nursing service needs. 
Regarding rehab services, you are independent with bed mobility, and declined therapy intervention. Although 
there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a 
daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 
setting. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.
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 enrollee requires a higher level of care. You also 
say that the enrollee needs to be medically managed by a physician daily. The Plan denied your request. The 
Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a lower level of care. Our reviewer found that the enrollee is requiring 
some assistance for certain activities of daily living, but a less intensive, longer duration of therapy will allow 
for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not 
warranted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care after September 16, 2020. 
 
You asked the Plan to pre-approve continued SNF care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not require ongoing skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered 
date. You do not have complex wound care or other ongoing SNF level SN need.  
 
Your functional level does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF beyond the last covered date. You do not require skilled nursing or skilled therapy services 
(or a combination of these services) on a "daily basis" in a SNF beyond the last covered date. As a practical 
matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting 
beyond the last covered date. 
 
 
 
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 SNF care after September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee has been using this 
surgeon for years. The Plan denied your request. The Plan says there are providers within the network that can 
treat disorders of the teeth. 
 
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.  
 
We looked at the file, and Medicare rules. The Plan contract says that the enrollee can use any licensed dental 
provider who is eligible under Medicare. The documentation in the case file does not indicate the provider at 
issue is able to provide services under Original Medicare. Based on this information, we decided that the Plan's 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve dental 
services to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that you are not able to care for yourself at home. 
The Plan denied your request. The Plan says you do not have any daily skilled nursing or therapy service needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer 
found that from a nursing perspective, you had stable vital signs, and received routine catheter care. There are 
no identifiable skilled nursing service needs. Regarding rehab services, you require assist with functional 
mobility and all activities of daily living at baseline. There are no identifiable skilled therapy service needs. 
You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or 
intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.
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 review of the medical records, you do not meet the CMS coverage criteria 
for an IRF admission based on lack of medical and nursing needs and current functional status. There is no 
evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. The 
documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an 
interdisciplinary approach to rehab care. You do not meet the CMS coverage criteria for an IRF admission. 
Your rehab needs can be met in an alternate, less intense setting. 
 
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: 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 you feel the denial for a rehabilitation stay would 
jeopardize any chance the enrollee has of a full recovery. The Plan denied your request. The Plan says the IRF 
services being requested do not meet the requirements for approval. 
 
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. Our reviewer 
found that the medical record supports a need for physical and occupational therapy, but it does not support a 
need for an intensive rehabilitation therapy program. Our physician reviewer also found that there is not a 
reasonable expectation that this 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that a respiratory therapist creates a customized care 
plan for each enrollee. The Plan denied your request. The Plan says the requested services are available in-
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these OON items. Therefore, we decided that the Plan does not have to pre-approve durable 
medical equipment to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion Indirect Decompression System for 
implantation of Superion spinal spacer coded as 22870 and 22869. 
 
You asked the Plan to pre-approve the Superion spacer device for interspinous decompression. You say that 
you believe this service is medically necessary and request reconsideration. The Plan denied your request. The 
Plan says there is lack of evidence to support that interspinous spacer devices are as safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Superion spacer device for interspinous decompression have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion Indirect Decompression System for 
implantation of Superion spinal spacer coded as 22870 and 22869.