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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been 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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
has not been met. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found in the setting of reirradiation, particularly when treating a complex nodal target volumes, proton 
therapy would be considered to furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have been met. Therefore, we decided that the Plan has to 
pre-approve proton beam therapy.  
 
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 MyoPro Motion G Orthotic device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this device has deluxe features that exceeds the enrollee's needs and replaces, 
rather than improves the function of the enrollee's arm. 
 
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 requested items/services are not considered medically reasonable and necessary in this case. At this time the 
requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical 
condition/function of hemiparesis after stroke than any available standard therapy. The requested device is not 
the standard of care for hemiparesis after a stroke over standard treatment including treatment such as  physical 
and occupational therapy, strengthening exercises, constraint induced movement therapy, Botox injections for 
spasticity. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a 
MyoPro Motion G Orthotic device. 
 
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 MyoPro Motion G Orthotic device for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation SNF services after October 30, 2020. 
 
You asked the Plan to pre-approve continuation of SNF services. The Plan denied your request. The Plan says 
continuation of SNF services is not medically necessary at this time. The medical records provided indicate that 
you are stable and appropriate for discharge. 
 
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 continuation of SNF services. Our 
reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a 
nursing perspective, you received oral medications. You had stable vital signs. Regarding rehabilitation 
services, you received physical therapy (PT) and occupational therapy (OT) in the SNF.  By the dates in 
question, you were at an independent to supervision/stand by assist to contact guard assist level with functional 
mobility including gait to 100 feet with a rolling walker. You required varying assist with activities of daily 
 
 
living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service 
needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of SNF services after October 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with power seat elongation system 
(E2300 and E2331). 
 
You asked the Plan to pre-approve a power seat elevation system. We note the Plan approved the power 
wheelchair and Medicare covered accessories.. You say that a power seat elevation system is medically 
necessary. The Plan denied your request. The Plan says a power seat elevation system is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  Medicare specifically states this accessory is not covered. Therefore, we decided that the 
Plan does not have to pre-approve a power wheelchair with power seat elongation system (E2300 and E2331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Guardian 3 sensor for a Medtronic 670G. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that you need this sensor to start back 
up on your insulin. The Plan denied your request. The Plan says the denial of authorization for this item is 
correct, because this glucose monitor sensor does not meet the criteria for a therapeutic continuous glucose 
monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor that does not 
replace a blood glucose monitor for making diabetes treatment decisions is not covered.  
 
We looked at the file and Medicare rules. This Guardian 3 device is not intended to replace a blood glucose 
monitor for making diabetes treatment decisions. Therefore, it is not considered a therapeutic CGM and is not 
covered. 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 Guardian 3 sensor for a 
Medtronic 670G.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your care can be handled in a less intensive setting. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for left knee pain after a fall. You 
were diagnosed with acute gout and acute on chronic kidney injury. Your medical problems are stable. There 
are no identified problems that need inpatient medical management. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and 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 you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF care. 
 
 
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been 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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care.  
 
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 deep brain stimulation (DBS) for obsessive compulsive 
disease (OCD) treatment for the enrollee. 
 
You asked the Plan to pre-approve DBS for OCD treatment. You say that this treatment offers the enrollee the 
best opportunity to return to work and to enjoy a meaningful improvement in her quality of life. The Plan 
denied your request. The Plan says that this is not covered under the current Medicare Category B 
Investigational Device Exemption Requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that providers participating in and seeking Medicare 
reimbursement for items and services in Category A or B IDE studies, prior to submitting claims, are 
responsible for checking the CMS Coverage Website to identify whether CMS (or its designated entity) has 
approved the study for purposes of Medicare coverage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the DBS for OCD treatment have not been met. Specifically, the provider to render treatment in 
this case is not listed as an approved provider for this Category B IDE study. Therefore, we decided that the 
Plan does not have to pre-approve deep brain stimulation (DBS) for obsessive compulsive disease (OCD) 
treatment for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oncological services to be provided by an out of 
network (OON) tertiary-level provider. 
 
You asked the Plan to pre-approve the OON tertiary oncology care. You say that it is felt that the enrollee 
needs the expertise of this provider due to the high risk of infection and complex nature of his cancer and 
necessary treatment in the presence of cirrhosis and a biliary stent. The Plan denied your request. The Plan says 
the enrollee has been offered an in network oncologist to have his condition treated. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 OON tertiary oncology care. Our reviewer says that the requested 
treatment from an OON tertiary provider is not shown to be medically reasonable and necessary. Our physician 
reviewer found the enrollee has hepatocellular carcinoma with a plan for Y90 embolization therapy. Y90 
therapy with dosimetry can be furnished by a network provider. Tertiary care for this condition 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 OON tertiary oncology care have not been met.  
 
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 the OON tertiary oncology care. Therefore, we decided 
that the Plan does not have to pre-approve the oncological services to be provided by an out of network (OON) 
tertiary-level provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that custodial care is not covered by Medicare. 
 
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 the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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) 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 these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate care in the acute care hospital. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. You appear 
to be improving, but require additional short term acute care services (less than 25 days) to determine longer 
term hemodialysis needs and for postoperative cardiac monitoring which could be completed at the current 
facility. You do not require services at the LTACH that are not already available at the current facility. Our 
physician reviewer found that your condition does not meet Medicare criteria for LTACH services. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz injections. 
 
You asked the Plan to pre-approve the Supartz injections. You say that the enrollee requires this treatment. The 
Plan denied your request. The Plan says this can only be covered if a trial of Monovisc fails. 
 
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 the Supartz injections. Our reviewer 
says that the requested drug is not considered reasonable and necessary based on step therapy criteria. Our 
physician reviewer found there is no evidence of a trial of the preferred drug, Monovisc. 
 
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 Supartz injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Supartz injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis, comprehensive oral evaluation and intraoral 
x-rays provided on May 11, 2020. 
 
You asked the Plan to pay for the prophylaxis, comprehensive oral evaluation and intraoral x-rays. You say that 
your provider says that you couldn't have surgery if you did not complete a dental visit prior. The Plan denied 
your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the prophylaxis, comprehensive 
oral evaluation and intraoral x-rays provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on July 2, 
2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
We find that CPT code 99100 is not supported in the medical record. Specifically, this service has been 
bundled as it is considered components of the same procedure. Review of the file shows that code 00534 has 
already been approved and processed by the plan. This code is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on 
July 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that requested CPT codes are not supported in the medical record. Specifically, the records do not 
show that the lab services were performed on a blood specimen collected by venipuncture. The records show 
that a urine specimen was collected. 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 pay for the lab services 
provided on March 10, 2020.