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

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
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 admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the submitted records show that you 
were exposed to COVID on September 14, 2020. You received oral and inhaled medications and had stable 
vital signs. You did not receive any skilled therapy. You have no skilled nursing needs. You have skilled 
therapy needs, but do not require skilled therapy on a daily basis. As a practical matter, you do not require the 
necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient psychiatric days from September 
22, 2020 and forward. 
 
You asked the Plan to pre-approve additional inpatient psychiatric days from September 22, 2020 and forward. 
You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says 
the enrollee has exhausted the lifetime inpatient psychiatric benefit and no further care can be provided. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for inpatient psychiatric care is limited 
to 190-days in a patient's lifetime. The contract with the Plan also states this. 
 
Based on the Medicare database, the enrollee has received 190 days of inpatient psychiatric care. As such, no 
further inpatient psychiatric coverage is available. Therefore, we decided that the Plan does not have to pre-
approve additional inpatient psychiatric days from September 22, 2020 and forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary 
osteoarthritis of the right knee. She has not tried and failed the Plan's required drugs of Orthovisc and 
Monovisc. The records do not show that the required drugs would be contraindicated or less effective; 
therefore, Supartz FX is not reasonable or medically necessary at this time. 
 
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 Supartz FX.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that the requested proton beam radiation therapy is 
medically necessary. The Plan denied your request. The Plan says the requested proton beam radiation therapy 
is 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 PBRT. Our reviewer says that the 
requested proton beam radiation therapy is not medically necessary. Our physician reviewer found the bottom 
line is that proton therapy for prostate cancer is not experimental, and in fact is an accepted treatment approach.  
While I do not think that proton therapy is an experimental therapy, any potential benefit or detriment of proton 
therapy over standard IMRT is an investigational question (being pursued in randomized studies- i.e. for 
intermediate to low risk prostate cancer  - https://clinicaltrials.gov/ct2/show/NCT01617161 -' Proton Therapy 
vs. IMRT for Low or Intermediate Risk Prostate Cancer (PARTIQoL)' ). Other treatment approaches (IMRT 
+/- IGRT) are also highly effective and well tolerated.  Thus, whether proton therapy affords a benefit over 
other standard approaches (IMRT/IGRT) for prostate cancer is an area of investigation and remains 
controversial.  Particularly with the use of the SpaceOAR hydrogel spacer, the risk of GI/rectal toxicity is low 
(since the rectum is pushed away from the prostate) such it is even more unlikely that there would be a 
potential benefit from proton therapy. 
  
To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than 
IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy 
on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve continued home health care services. 
 
You asked the Plan to pre-approve home health services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says that the enrollee no longer meets criteria. 
 
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing 
coverage of home care services.  
 
There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services 
at issue in this appeal. Therefore, we decided that the Plan has to pre-approve continued home health care 
services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two of the epidural injections (64483 and 64484). 
 
You asked the Plan to pre-approve four injections. You say that you would like reconsideration because these 
injections are medically necessary to treat the member's conditions. The Plan denied your request. The Plan 
says no more than two transforaminal injections may be performed at a single setting. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than two transforaminal injections may 
be performed at a single setting. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injections have not been met. You are requesting four injections, but per Medicare, only two 
are allowed in a single setting. Therefore, we decided that the Plan does not have to pre-approve two of the 
epidural injections (64483 and 64484).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary 
because the enrollee still needs prescription medical management. The Plan denied your request. The Plan says 
SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have skilled 
nursing service needs. The enrollee may benefit from continued skilled therapy services but does not require 
them on a daily basis. The documentation does not support that the enrollee in this case requires daily skilled 
services on an inpatient basis in a SNF. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Thyrogen. 
 
You asked the Plan to pre-approve a tier exception. You say that the high cost of the medication places a 
financial burden on the enrollee. The Plan denied your request. The Plan says a tier exception cannot be 
granted for Part B medications. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare Part B prescription drugs.  
 
The enrollee has been asked to pay a 20% coinsurance for the requested medication. The drug falls within the 
Medicare Part B prescription drugs benefit category. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pre-approve a 
tier exception for Thyrogen.
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 outpatient visits. You say that you would like reconsideration because 
this is the provider who rendered your surgery and you are satisfied with their expertise. The Plan denied your 
request. The Plan says your group has referred you to a local surgeon who specializes in cancer and has similar 
expertise. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of lumbar or sacral single facet joint 
injection (64635) and destruction of lumbar or sacral each additional facet joint injection (64636). 
 
You asked the Plan to pre-approve destruction of lumbar or sacral single facet joint injection and destruction of 
lumbar or sacral each additional facet joint injection. 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 follows Medicare rules. Medicare rules say that Therapeutic Facet Joint Injections are covered when 
specific criteria has been 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 destruction of lumbar or sacral single 
facet joint injection and destruction of lumbar or sacral each additional facet joint injection. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the provided medical records do 
not document that the enrollee has satisfied the coverage criteria. Therefore, the requested injections 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 destruction of lumbar or sacral single facet joint injection and destruction of 
lumbar or sacral each additional facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve destruction of lumbar or sacral single facet joint injection (64635) and destruction 
of lumbar or sacral each additional facet joint injection (64636).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued SNF stay. 
 
You asked the Plan to pre-approve the continued SNF stay. You say that you are requesting an appeal to extend 
insurance coverage for the enrollee. You also say that the enrollee needs to continue with as much therapy as 
possible per week, in hopes that his body continues to improve. The Plan denied your request. The Plan says 
Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from March 5, 2020 to 
July 25, 2020. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve a continued SNF stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skin Barrier Wipes or Swabs (A5120). 
 
You asked the Plan to pre-approve the skin barrier wipes or swabs. You say that the skin barrier items are 
medically necessary. The Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that the quantity of ostomy supplies needed by a 
beneficiary is determined primarily by the type of ostomy, its location, its construction, and the condition of the 
skin surface surrounding the stoma.  
 
We looked at the file and Medicare rules. The items requested are considered ostomy supplies. The record does 
not show that the enrollee has an ostomy. Based on this information, we decided that Medicare rules for 
coverage of the skin barrier wipes or swabs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Skin Barrier Wipes or Swabs (A5120).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. 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 a wireless capsule endoscopy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the primary indications for wireless capsule endoscopy are evaluation of 
suspected small bowel bleeding (including patients with iron deficiency anemia), the diagnosis of suspected 
Crohn's disease, and for the diagnosis of small bowel tumors. The enrollee has iron deficiency which has not 
responded to standard therapy, and a small bowel source of bleeding is 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 a wireless capsule endoscopy have been met. Therefore, we decided that the 
Plan has to pre-approve a wireless capsule endoscopy (91110).  
 
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 consultation with a urologist. 
 
You asked the Plan to pre-approve the urology consultation. You say that you feel that you should not have to 
have a psychology referral in order to be seen by a urologist for this condition. You say that this is not 
something related to any psychological issue and you want to be evaluated for physical medical issues causing 
this. The Plan denied your request. The Plan says your provider indicates that counseling should be tried prior 
to a urology referral. However, there is also no reason why a trial of an ED drug would not be reasonable 
before a referral to urology. 
 
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 urology consultation. Our reviewer 
says that the requested consultation is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific clinical rationale for the requested urology referral. The medical 
records do not show any contradictions to PDE-5 therapy (Viagra, Cialis, Levitra) and there is no 
documentation of any lab studies such as a morning total/free testosterone. In addition, there is no 
documentation indicating the enrollee has undergone any psychological counseling for his condition. The 
review has determined that the requested urology consultation is not medically reasonable or necessary at this 
time. 
 
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 urology consultation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve consultation with a urologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex spacer. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of back pain. 
The requested Vertiflex spacer is considered experimental in nature, as more research is needed to show its 
safety and efficacy. The services are therefore 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 Vertiflex spacer.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve 6 additional physical therapy visits. You say that you have Parkinson's 
disease and the only way to exercise is if you have physical therapy. You say that it's medically necessary. The 
Plan denied your request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 6 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the unique skills of a professional therapist are 
not required to safely and effectively provide ongoing treatment. Our reviewer says that you should be able to 
transition to an independent home exercise program with the already authorized therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional physical therapy visits.