Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out of network provider 
at the in network benefit level. 
 
You asked the Plan to pre-approve the continuation of care with an out of network provider at the in network 
benefit level. You say that the in-network doctor you saw in 2003 failed to identify the cancer in your other 
breast. You say that this is a highly specialized invasive surgery. You say that you would like to continue care 
with the doctor you saw in 2003 and that you need the services covered as in-network since you are on a fixed 
income. The Plan denied your request. The Plan says the requested provided is out of network. The Plan says 
that there are 3 in network providers who can treat the enrollee's condition. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care with an out of 
network provider at the in network benefit level. Our reviewer says that the criteria for coverage have not been 
met. Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering 
adequate care to meet the enrollee's medical needs through referral to an in-network provider.  
 
 
 
 
There is nothing unique about the enrollee's condition that would make it medically necessary to see the 
requested out of network provider. The Plan has shown that they have in-network providers who meet the 
Standards of Care required for treatment of the enrollee's condition. The enrollee is not currently receiving any 
active treatment and/or medical management of her condition that makes it medically necessary for the enrollee 
to continue care with the out of network provider as requested. 
 
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 continuation of care with an out of network provider at the in network 
benefit level have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuation of care with an out of network provider at the in network benefit level.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that the requested RFA is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
radiofrequency ablation (RFA). 
 
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 radiofrequency ablation (RFA). Our 
reviewer says that the enrollee does not meet criteria for the radiofrequency ablation (RFA). Our physician 
reviewer found the records show that the enrollee has radicular leg symptoms. This is a contraindication to 
facet injections. There is no clear pain localizing study to determine the facet joints are painful. Facet injections 
are not indicated in this enrollee with leg symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation (RFA) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the enrollee has 
not met the step therapy requirements. 
 
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 Synvisc-One. Our reviewer says that 
the enrollee has not met the step therapy requirements for coverage of Synvisc-One. Our physician reviewer 
found that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. The 
documentation does not outline contraindications or reasons these medications were not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve leadless pacemaker insertion. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are covered when 
performed in a FDA-approved study. 
 
We looked at the file and Medicare rules. The file shows that the services are not being requested in relation to 
a FDA-approved study. 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 leadless 
pacemaker insertion.
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 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. 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 was admitted for altered mental status, seizure, and hypertensive 
emergency. All medical problems are now stable and she has no complex nursing or rehabilitation needs. She 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that she will be able to fully 
participate in and benefit from 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that 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 based on the medical records, you do not 
require skilled nursing or therapy services on a daily basis. Your condition does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria 
are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a balloon sinuplasty. 
 
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 an unspecified nasal 
polyp with reported rhinorrhea, facial pressure, and nasal obstruction. A computed tomography (CT) scan of 
the sinuses on September 4, 2020 demonstrated moderate pansinus disease. Sinuplasty may be considered for 
patients that remain symptomatic despite medical therapy. It has not been adequately demonstrated that the 
enrollee in this case has failed a course of appropriate medical therapy; therefore, the procedure is not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a balloon sinuplasty.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the PET with concurrently acquired computed tomography (CT) 
for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that you have a history of prostate cancer. The Plan 
denied your request. The Plan says that the documentation available does not support the Medicare criteria for 
coverage, more specifically because the medical records indicate that you were diagnosed with prostate cancer 
in March 2013 and have not had any treatments for your cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our physician reviewer 
found the subsequent treatment strategy is covered for prostate cancer. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve the PET with concurrently acquired computed tomography (CT) for attenuation correction and 
anatomical localization imaging; skull base to mid-thigh (CPT Code 78815).
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 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. 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. Our 
physician reviewer found the enrollee was admitted to the hospital with recently-treated bacteremia, chest and 
neck pain, and night sweats. He was treated with intravenous (IV) antibiotics. He does not require services at 
the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not available and covered at the current facility. The LTACH services are not 
reasonable or 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 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the thoracic spine. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a five-year history of back 
pain that is now radiating. He has failed chiropractic therapy and has seen pain management in the past. Given 
the chronic nature of the pain with radiation and failed chiropractic care and prior pain management, the MRI is 
indicated for treatment to determine the severity of the problem. The MRI is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the thoracic spine.  
 
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 power scooter (PMD). 
 
You asked the Plan to pre-approve a power scooter. You say that a power scooter is medically necessary. The 
Plan denied your request. The Plan says Medicare coverage criteria for a power scooter are not met. 
 
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.  
 
There is no evaluation provided from your physician. The records do not show that you have tried and failed a 
cane, walker, walker with wheels or manual wheelchair inside the home. Medicare does not cover a power 
scooter for use outside of the home. Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power scooter (PMD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sphenopalatine ganglion block. 
 
You asked the Plan to pre-approve a sphenopalatine ganglion block. You say that the block is a non-invasive 
procedure to treat the enrollee's headaches. 
 
The Plan denied your request. The Plan says medical literature does not support the appropriateness for the 
enrollee's condition. 
 
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 a sphenopalatine ganglion block. Our 
physician reviewer found that the enrollee has a history of chronic headaches. A computed tomography (CT) 
scan of the head demonstrated she may have a frontal CSF hygroma vs atrophy. The headaches are located in 
the bilateral fronto-temporal area without features of cervicalgia or migranoous features. The requested blocks 
do not demonstrate effectiveness for the treatment of cluster headaches and other chronic headache syndromes. 
The role of the sympathetic nervous system in migraine is still not well understood, and there are no evidence-
based guidelines at present that support sympathetic or somatic nerve block. The requested block is not safe 
and effective to treat the enrollee's condition. The requested block is not medically reasonable or necessary to 
treat the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sphenopalatine ganglion block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a sphenopalatine ganglion block.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Cytarabine HCL (J9100). 
 
You asked the Plan to pre-approve Cytarabine HCL (J9100). You say that the requested Cytarabine HCL is 
medically necessary. The Plan denied your request. The Plan says that the requested Cytarabine HCL is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's 
failure to obtain records that are within the plan's control. Therefore, we decided that the Plan has to pre-
approve Cytarabine HCL (J9100).  
 
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 the replacement of a power mobility device (PMD). 
 
You asked the Plan to pre-approve the PMD replacement. You say that the enrollee meets the criteria for 
coverage of a PMD and that the current device is wobbly and not working properly. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment is 
never less than 5 years.  
 
We looked at the file and Medicare rules. The records show that you have had your current power mobility 
device for less than 5 years. Based on this information, we decided that Medicare rules for coverage of the 
PMD replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
replacement of a power mobility device (PMD).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare criteria for IRF admission are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-
approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and 
necessary based on Medicare guidelines. Our physician reviewer found the 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 shortness of breath and 
worsening end stage renal disease. He was treated for congestive heart failure and hemodialysis was initiated. 
All 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, and an 
intensive rehabilitation therapy program. The records do 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 for the enrollee.