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

 
We decided that the Plan has to pre-approve apheresis for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered for treatment of sickle cell anemia. 
 
The Plan must follow Medicare rules. Medicare rules say that apheresis is covered under various indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found scheduled apheresis in patients with sickle cell disease is a standard treatment option for regularly 
scheduled transfusions used in the prevention of stroke, acute chest syndrome, and recurrent painful episodes. 
This enrollee has recurrent painful episodes and is unable to tolerate his current treatment. The service is 
reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Although sickle cell anemia is not directly 
listed in the NCD, the NCD does not specifically exclude other indications. Based on this information, we 
decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has 
to pre-approve apheresis 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is 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 patient appears to be improving but still requires short term acute care services to 
help with basic wound care at this stage. The patient does not require services at the LTACH that are not 
already available at the current facility. There are no services at the LTACH that are not already available and 
covered at the current facility. Therefore, this request for LTACH will be considered not medically necessary at 
this time. It appears appropriate to continue care at the current facility until ready and appropriate for a transfer 
to a lower level of care soon. 
 
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup services (D2950). 
 
You asked the Plan to pre-approve the core buildup services. You say that you have a crack in this tooth and it 
is causing you pain and discomfort. The Plan denied your request. The Plan says the service which remains in 
dispute is not a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup services (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclobenzaprine tablets. 
 
You asked the Plan to pre-approve the Cyclobenzaprine tablets. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says they only provide Part A and Part B coverage for the 
enrollee, and not Part D coverage. 
 
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 Cyclobenzaprine tablets.  
 
Benefits for the Cyclobenzaprine tablets 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 medical 
services to be provided by an out-of-network provider.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital after a fall off of a ladder. She sustained a broken hip and pelvis. The records do not show evidence of 
medical issues that require monitoring by an inpatient rehab physician three times a week. The documentation 
does not support that there is a need for an intensive therapy program with three hours a day and an 
interdisciplinary approach to rehab care. The IRF 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transport trips (A0120). 
 
You asked the Plan to pre-approve the additional routine transport trips. You say that the additional trips are 
medically necessary. The Plan denied your request. The Plan says your transportation benefit has been 
exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transport trips (A0120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra 5% drops. 
 
You asked the Plan to pre-approve Xiidra 5% drops. You say that you would like the plan to reconsider their 
denial The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Xiidra 5% drops.  
 
Benefits for Xiidra 5% drops 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our physician 
reviewer found based on the medical records provided there is no documentation that show that skilled nursing 
services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's 
condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent 
deterioration. There is no documentation of any acute unstable condition and no documentation of a physician's 
assessment or order for home health nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve the automatic blood pressure monitor. You say that you do not think you 
will be able to understand the standard blood pressure cuff. You say that automatic blood pressure cuffs are 
also not as accurate as a digital one. The Plan denied your request. The Plan says the requested device is a non-
covered item. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmology outpatient visit (76510, 92242, 
92134, 99205) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology outpatient visit. You say that you need a new 
authorization for services because the member has a history of retinal detachment and retinopathy. The Plan 
denied your request. The Plan says you have been referred to a provider in the network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the ophthalmology outpatient visit (76510, 92242, 92134, 99205) 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 prefabricated post and core services (D2954). 
 
You asked the Plan to pre-approve the prefabricated post and core services. You say that you have a cavity 
under the tooth that was denied. You say that you are having extreme pain and sensitivity. The Plan denied 
your request. The Plan says the service being requested is not a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated post and core services (D2954).
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 would like the plan to reconsider their denial 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were non-weight bearing on the right lower extremity and partial weight bearing 
on the lower upper extremity. The documentation does not support that the complexity of your nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. While you require additional physical therapy and occupational therapy, you do not require 
an intensive therapy program. 
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is 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 patient appears to be improving but still requires short term acute care services. 
The patient does not require services at the LTACH that are not already available at the current facility. There 
are no services at the LTACH that are not already available and covered at the current facility. Therefore, this 
request for LTACH will be considered not medically necessary at this time. It appears appropriate to continue 
care at the current facility until more stable and ready for a transfer to a lower level of care soon. 
 
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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device 
(Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because this is 
experimental/investigational 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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is experimental. More research is needed to show its safety and efficacy. There is no 
documented spinal instability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interspinous stabilization device (Vertiflex).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of facial bones (CPT code 21026) provided on 
March 19, 2020. 
 
You asked the Plan to pay for the excision of facial bones. You say that the records provided support that the 
services in dispute were medically necessary. The Plan denied your request. The Plan says the request is dental 
in nature and is not covered by the medical plan, per CMS guidelines. 
 
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 
the enrollee's teeth or the structures directly supporting the enrollee's teeth. The records show that the bony 
sequestra was related to the extraction of tooth #14 and #15. 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 excision of facial bones 
(CPT code 21026) provided on March 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Free Style Libre 14 Day sensor. 
 
You asked the Plan to pre-approve the Free Style Libre 14 Day sensor. You say that the requested sensor is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
coverage. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are covered 
for certain medical indications and when 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 Free Style Libre 14 Day sensor. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a 
diagnosis of type II diabetes mellitus with nephropathy. Based on the medical records provided there is no 
documentation that the enrollee is on multiple daily insulin injections or is using a Medicare-covered 
continuous subcutaneous insulin infusion pump. 
 
 
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 Free Style Libre 14 Day sensor have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Free Style Libre 14 Day sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation devices 
(HFCWOD) for the enrollee. 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. 
This means that you do not have a medical condition for which a high frequency chest wall oscillation devise 
can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a 
high frequency chest wall oscillation devices (HFCWOD) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osseous, osteoperiosteal, or cartilage graft (D7950).  
 
You asked the Plan to pre-approve the osseous, osteoperiosteal, or cartilage graft (D7950). You say that there is 
not enough bone to secure a permanent replacement crown. You say that the sinus lift is needed to complete the 
secure replacement. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
osseous, osteoperiosteal, or cartilage graft (D7950).