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

 
We decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT services. The Plan denied your request. The Plan says that the 
records do not show that the enrollee has previously received radiotherapy to his pelvic region. 
 
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 IMRT services. Our physician reviewer 
found that IMRT for rectal cancer is used to reduce dose to the small bowel, bladder, pelvic bone marrow and 
femoral heads.  Rectal cancer can readily be treated in the neoadjuvant setting (curatively) with conventional 
radiation, while maintaining acceptable dose constraints to the bladder, femurs and bowel. IMRT can be 
considered for exceptional circumstances. This enrollee is being treated to a higher dose (60 Gy) than those 
treated with neoadjuvant or adjuvant radiotherapy (50-54 Gy), as the plan is definitive chemoradiation with no 
surgery. This case is also unique due to the anal invasion of the cancer, which would result in some radiation 
oncologists treating inguinal nodes, which does not appear to be the case for this enrollee. The IMRT plan 
results in better target coverage and better bladder sparing, which would be clinically meaningful in this 
enrollee, who will not undergo resection. While the bladder is relatively tolerant to radiotherapy, and the 3D 
plan meets QUANTEC constraints, the better target coverage that IMRT allows supports the need for IMRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT services have been met. Therefore, we decided that the Plan has to pre-
approve Intensity Modulated Radiation Therapy (IMRT).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee 
does not need more skilled therapy, wound, or medical care. 
 
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. 
 
Continued SNF care beyond August 30, 2020, was requested for 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 continued services. Our physician reviewer found that from a nursing 
perspective, the enrollee received oral medications, had stable vital signs, and had uncomplicated wound care. 
There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a maximal 
assist to dependent level with bed mobility and transfers. He requires varying assist with activities of daily 
living. There are no identifiable skilled therapy service needs. He does not require skilled nursing or therapy 
services on a daily basis. The enrollee does 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a fenestrated graft for abdominal aortic aneurysm repair. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that 
there is not enough medical proof that shows the safety or success of a fenestrated graft for repair of an 
abdominal aortic aneurysm. 
 
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 the requested services. Our physician 
reviewer found that the enrollee is status post open aortic aneurysm repair in the past, and now has developed 
an aneurysm of the aorta above the previous graft, at level of the renal arteries measuring 6 cm in maximal 
diameter. This is a significant increase in size from his previous measurements. The enrollee's age, previous 
abdominal surgery, and renal artery involvement put him at high risk for traditional open repair. The requested 
device has been shown to be safe and effective. The proposed procedure, endovascular repair with a fenestrated 
device, is both reasonable and medically necessary as it presents the most viable option for 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 been met. Therefore, we decided that the Plan has to 
pre-approve a fenestrated graft for abdominal aortic aneurysm repair.  
 
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 pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON medical services. You say that you have an ovarian mass that 
needs to be removed or you may die. The Plan denied your request. The Plan says the surgery services you 
require can be provided by an in network provider. The Plan says that authorizations have been approved and 
are on file for the requested surgery with an in network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does 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 enrollee's medical status does not currently require intensive physician and 
nursing oversight only in an IRF. Our reviewer also found that the enrollee may benefit from multiple therapies 
such as physical and occupational therapy, but the documentation does not support that the enrollee's functional 
status requires an 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: 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 needs inpatient rehab. The Plan denied 
your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee presented to the 
hospital on August 11, 2020 after a fall at home. He was diagnosed with fall, sepsis, urinary tract infection, and 
a chronic wound. In physical therapy on August 21, 2020 he needed modified assist rolling in bed and maximal 
assist with sit to supine. He is limited by pain and weakness. The complexity of his nursing, medical, and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. He may benefit from multiple therapies but does not require an intensive therapy program 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: 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 will need a hospital level of care for 
rehabilitation, with close medical management. The Plan denied your request. The Plan says the IRF admission 
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 enrollee's medical status does not currently require intensive physician and 
nursing oversight only in an IRF. Our reviewer also found that the enrollee may benefit from multiple therapies 
such as physical and occupational therapy, but the documentation does not support that the enrollee's functional 
status requires an 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 a power wheelchair and accessories for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no notes from a recent face-to-face exam with a physician. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services are not medically reasonable or necessary. Our physician reviewer found the enrollee has a 
personal mobility deficit but the documentation does not reveal supporting physician or medical office visits 
progress note that support that this deficit impairs participation in MRADLs and a detailed neuromuscular 
physician or medical office visit documented neuromuscular examination that supports that the enrollee cannot 
overcome this deficit with a manual wheelchair, walker, cane. The documentation notes on the wheelchair 
assessment that the enrollee has weakness in the upper extremities, and therefore cannot help his deficit with a 
manual wheelchair, walker, or cane. The documentation does not support that the patient is unable to perform a 
functional weight shift, uses intermittent catheterization for bladder management on objective physician or 
treatment medical provider office notes. There is no objective physician or treating medical provider progress 
report measuring the enrollee's spasticity on an Ashworth scale that indicates the enrollee requires a power 
seating system to manage increased tone or spasticity. 
 
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 a power wheelchair and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral formula (B4154). 
 
You asked the Plan to pre-approve enteral formula. You say that this should be covered because you were in 
the hospital with low blood sugars, you are experiencing higher blood sugars, you are not comfortable with the 
Gluverna for the "spikes", it is too expensive for you to buy and if you do not know if there is a generic. The 
Plan denied your request. The Plan says the eternal formula is not 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 enteral formula. Our physician reviewer 
found the patient can take Glucerna on their own accord, but there is no medical need/justification for enteral 
feeding in this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of enteral formula have not been met. Therefore, we decided that the Plan does not 
have to pre-approve enteral formula (B4154).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of brow ptosis (67900). 
 
You asked the Plan to pre-approve the surgery. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says this service is cosmetic in nature. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the amblyopia is only affecting the left eye, yet the right eye demonstrates no improvement 
with eyelid taping for estimating improved visual field with surgery. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repair of brow ptosis (67900).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rest home visits (99336, 99337, 99354, 99358). 
 
You asked the Plan to pre-approve rest home visits. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says the records do not support that these services are medically necessary. 
 
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 rest home visits. Our reviewer says that 
the requested visits are not medically necessary. Our physician reviewer found the records do not show that 
skilled nursing services are required to effectively provide treatment, care, or services in order to improve the 
patient's condition, or to establish/perform a maintenance program to maintain the patient's condition or prevent 
deterioration. There are no complex wounds, new enteral feedings or other skilled nursing needs. The enrollee's 
chronic medical conditions are stable. Venipuncture alone is not a home health skilled nursing need. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rest home visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve rest home visits (99336, 99337, 99354, 99358).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
he Plan follows Medicare rules. Medicare rules say that facet joint blocks are covered when the above 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 the injection. Our reviewer says that the 
requested facet joint injection is not medically reasonable and necessary. Our physician reviewer found that the 
requested procedure is supported for predominantly axial pain that is not associated with radiculopathy or 
neurogenic claudication. Radiculopathy is documented in the provided notes. Therefore, based upon the 
submitted records and the information in the applicable LCD), the requested services are not medically 
reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a RACZ procedure for the Lysis of Adhesions (62264). 
 
You asked the Plan to pre-approve the RACZ Lysis of Adhesions. You say that the RACZ procedure is 
medically necessary. The Plan denied your request. The Plan says the requested procedure is not medically 
necessary at this time. 
 
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 RACZ Lysis of Adhesions. Our 
reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the documentation does not reveal objective evidence or imaging evidence of 
adhesions, or clear history and physical exam that indicates that the patient's symptoms are due to adhesions. 
There is no recent lumbar spine imaging report in the documentation. The most recent documentation indicates 
no history from the enrollee with subjective complaints. There is no detailed neuromuscular exam with 
evaluation of motor, sensory, reflex changes, or provocative testing of the lumbar spine. 
 
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 RACZ Lysis of Adhesions have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a RACZ procedure for the Lysis of Adhesions (62264).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve second opinion visit. You say that the Plan's in-network ophthalmologist has 
not been able to help you. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because this provider is out-of-network with the Plan and you can receive a second opinion 
within the Plan 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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.