Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. 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 was admitted for dizziness and falls with a non-
displaced fracture of C6 vertebra. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
enrollee is required to utilize 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve admission to an inpatient behavioral health facility for the 
enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that this is medically 
necessary. The Plan denied your request. The Plan says that an alternative level of care could be an outpatient 
program. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the requested admission is medically reasonable or necessary. Our physician reviewer 
found although the enrollee was not shown to be a danger to himself or others, he did have agitation/aggression 
and perceptual disturbance including auditory delusions. The health plan's denial of inpatient psychiatric 
services appears inappropriate. This enrollee did appear to require inpatient mental health 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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve admission to an inpatient behavioral health facility 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 pre-approve a Group 2 power wheelchair with accessories. 
 
You asked the Plan to pre-approve power wheelchair. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for this device is correct, because you do not meet the 
Medicare criteria for a Group 2 power wheelchair. 
 
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 power wheelchair. Our reviewer says 
that you do not meet the Medicare criteria for the requested power wheelchair. Our physician reviewer found 
the documentation is conflicting from the seating and mobility evaluation on June 9, 2020 by your physical 
therapist and the medical progress notes by your treating practitioner. The documentation by your treating 
practitioner reveals you have normal gait and station and are moving all extremities normally and walking with 
a walker. It also indicates no edema. However, the seating and mobility evaluation states that you have a 
mobility deficit interfering with mobility-related activities of daily living (MRADLs). Your mobility deficit is 
currently being helped by a walker. Your treating practitioner examination does not reveal a detailed upper 
extremity evaluation indicating that you are unable to use a manual wheelchair. The mobility evaluation reveals 
that you have the cognition and vision to safely operate a power mobility device, but the documentation does 
not support that this is medically necessary. Furthermore, the physical exam notes intact sensation which 
conflicts with the mobility evaluation diagnosis of diabetic neuropathy. In addition, your treating practitioner 
notes do not reveal that there is evidence of spasticity, a leg case, intermittent catheterization, leg edema, or 
clear inability to perform a weight shift that would require a tilt and recline and power elevating leg rests. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair with accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Protonix. 
 
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 Protonix.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Icatibant. 
 
You asked the Plan to pre-approve Icatibant. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Icatibant is not covered under the enrollee's Medicare Part B 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Icatibant.  
 
Benefits for Icatibant 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physician services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the physician services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are equally qualified in-network ENT specialists available to 
the enrollee that can provide the care and treatment the enrollee is requesting. 
 
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 physician services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete 
mandibular denture. 
 
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say 
that your dentures broke, and you are having a difficult time chewing. The Plan denied your request. The Plan 
says dentures are allowed one time every 60 months. The Plan also says that you received dentures less than 60 
months ago. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are limited to one set every 5 
years. The record shows that you last received a complete maxillary denture and a complete mandibular 
denture on July 12, 2016 and your dentures benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve a complete maxillary denture and a complete mandibular denture.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio for the enrollee. 
 
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your 
request. The Plan says that they did not receive documentation supporting the medical necessity for a step 
therapy exception. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Entyvio. Our reviewer says that 
Entyvio is not medically reasonable and necessary for the enrollee in this case. The enrollee has not trialed 
Stelara. The documentation does not outline contraindications or reason this medication was not considered. 
Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Entyvio. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve CT scan. You say that you are appealing. The Plan denied your request. The 
Plan says that the denial of authorization for this CT scan is correct. 
 
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 CT scan. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested CT scan. Our physician reviewer found the enrollee has a 
history of recurrent chest pain and dyspnea, and non-invasive evaluation to date has been unrevealing. Despite 
this she was recently re-admitted to the hospital with recurrent dyspnea after her initial cardiac evaluation. The 
enrollee is at increased risk for coronary artery disease (CAD). Although a nuclear scan was negative for 
ischemia and her overall prognosis is likely good, she has had recurrent anginal type symptoms and further 
invasive anatomic evaluation with cardiac catheterization would be reasonable. In patients who are likely to 
have a lower risk for severe disease, a coronary CT angiography scan can be a reasonable alternative to 
catheterization to rule out significant CAD in a patient with a negative non-invasive physiologic nuclear study 
but recurrent symptoms severe enough to warrant re-hospitalization. Therefore, CT angiography in this clinical 
instance is 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve 
a Computed Tomography (CT) scan of the heart.  
 
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 a pain pump trial. 
 
You asked the Plan to pre-approve the pain pump trial. You say that this should not be denied as many patients 
use both a spinal cord stimulator and a pain pump and have positive results. The Plan denied your request. The 
Plan says Medicare does not cover a pain pump in this situation. 
 
The Plan must follow Medicare rules. Medicare rules say that infusion pumps are contraindicated for enrollees 
with other implanted programmable devices. 
 
The records show that the enrollee has a programmable spinal cord stimulator. As such, the use of the infusion 
pump is contraindicated. Therefore, we decided that the Plan does not have to pre-approve a pain pump trial.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy surgery. 
 
You asked the Plan to pre-approve panniculectomy. You say that the enrollee has a history of hysterectomy and 
has maintained a stable weight. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because this procedure is cosmetic and 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 panniculectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of skin breakdown and the pannus does not overhang the pubis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve panniculectomy surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor and supplies. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that you would like 
reconsideration because your blood sugar spikes and dips and a continuous glucose monitor would assist in 
finding out what you are eating to cause this. The Plan denied your request. The Plan says you do not meet the 
required coverage criteria for this device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are 
covered by Medicare when the beneficiary is insulin-treated with multiple (three or more) daily injections of 
insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuous glucose monitor have not been met. Specifically, the record does not show that you 
are insulin treated. The record shows that you are currently taking oral medications for your condition. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor and 
supplies.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a mandibular partial denture (D5214). 
 
You asked the Plan to pay for the mandibular partial denture. You say that you have tried the denture on and 
they fit very well. The Plan denied your request. The Plan says that the documentation submitted demonstrates 
poor bone support on the remaining 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. The Plan covers the 
mandibular partial denture when the services are medically necessary and reasonable. 
 
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 the mandibular partial denture. Our reviewer 
says that this service meets coverage criteria. Our physician reviewer found there appears to be adequate bone 
support to meet the criteria for coverage for a mandibular removable partial denture (D5214). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the mandibular partial denture have been met. Therefore, we decided that the 
Plan has to pay for a mandibular partial denture (D5214).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the bilateral upper extremity joint. 
 
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 is insufficient clinical information to approve the requested study. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
Despite multiple attempts by the plan, records were not able to be received from the provider. 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 bilateral upper extremity joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  laser therapy. 
 
You asked the Plan to pre-approve the laser therapy. The Plan denied your request. The Plan says this is not 
FDA approved. 
 
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 laser therapy. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that laser therapy is not FDA approved for atrophic vaginitis or genitourinary 
symptoms of menopause. High quality data describing the safety, benefits, and appropriate use of vaginal laser 
therapy is lacking. Further research to better outline the indications, efficacy, safety and applications of this 
technology is needed before supporting its universal use. 
 
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 laser therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve laser therapy.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Leuprolide Acetate (J9217). 
 
You asked the Plan to pre-approve Leuprolide Acetate. You say that this drug has been effective for this 
enrollee. The Plan denied your request. The Plan says that this is not supported for the enrollee's condition. 
 
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 Leuprolide Acetate. Our reviewer says 
that the requested drug is considered safe, effective, and otherwise reasonable and medically necessary in this 
case. Our physician reviewer found the enrollee has advanced prostate cancer that has responded to this drug. 
The continuation of this drug is supported due to this response. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leuprolide Acetate have been met. Therefore, we decided that the Plan has to 
pre-approve Leuprolide Acetate (J9217).  
 
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.