Persius/hicric huggingface dataset:
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 developed acute hypoxic respiratory failure and is currently on 
vasopressor support. The record indicates that the enrollee is not clinically stable and requires ongoing acute 
care services. The record indicates that the enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. 
 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of a skilled nursing facility (SNF) 
admission. 
 
You asked the Plan to pre-approve continued SNF care. You say that you are not able to stand on your leg and 
walk again yet, and you need to continue these services in order to return home safely. The Plan denied your 
request. The Plan says it is not medically necessary for you to stay in the SNF. Documentation shows that you are not making progress and are refusing to participate in therapy or turn in bed to avoid bed sores. Based on 
these notes, it appears that you are ready to return to the long-term care facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found that you no longer require skilled 
nursing services which require the specialized skill, knowledge and judgement of a skilled professional nurse to 
safely and effectively provide medically necessary and reasonable treatment. You receive oral medications and 
have stable vital signs. At this time, you do not have skilled therapy needs which require the specialized skill, 
knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and 
reasonable treatment. You do 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continuation of a skilled nursing facility (SNF) admission.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says the service is not 
covered. 
 
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 a PET scan. Our physician reviewer 
found that the testing was requested for initial staging of prostate cancer. The records do not show that the 
enrollee has a covered indications for initial treatment strategy. Therefore, the requested scan is not considered 
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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Sambucol black elderberry gummies with vitamin C and 
Zinc purchased December 14, 2021. 
 
You asked the Plan to pay for black elderberry gummies. You say that these are immune support chewable with 
vitamin C and Zinc. The Plan denied your request. The Plan says black elderberry is not a covered supplement. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and black 
elderberry gummies is an OTC item. Therefore, we decided that the Plan does not have to pay for Sambucol 
black elderberry gummies with vitamin C and Zinc purchased December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided 
December 17, 2021. 
 
You asked the Plan to pay for the bitewing x-rays. You say that the x-rays were necessary, and the health 
system is screwed up. The Plan denied your request. The Plan says you have exceeded the frequency limit for 
this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the bitewing 
x-rays once per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that bitewing x-rays were 
previously covered on June 4, 2021. Based on this information, we decided that the Plan's frequency limit for 
coverage of the bitewing x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay 
for the bitewings - four radiographic images (D0274) provided December 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 18, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AlloSure molecular diagnostic testing provided on June 
28, 2021. 
 
You asked the Plan to pay for the AlloSure test. You say that this is a Medicare-covered test, and Medicare 
Advantage plans are required to reimburse this at the Medicare-allowed rate. The Plan denied your request. The 
Plan says the POS code reported is not appropriate for where the specimen was collected. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the AlloSure test have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the AlloSure molecular diagnostic testing provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam services (92002, 92015) provided on July 22, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the out-of-network vision care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says out-of-network services are covered only in certain 
limited circumstances. The enrollee self-referred for this care, the services were not urgent or emergent, and 
they were not pre-approved. Therefore, these services are denied. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eye exam services (92002, 92015) provided on 
July 22, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that a portable oxygen concentrator 
is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee currently has 
stationary equipment and canister tanks for home use. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. Medicare only covers oxygen equipment for home use. The enrollee has stationary 
oxygen and canister tanks for home use. This equipment serves the same purpose as a portable oxygen 
concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator 
for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a receiver (monitor), dedicated, for use with therapeutic 
continuous glucose monitor (CGM) system (K0554). 
 
You asked the Plan to pre-approve the receiver for therapeutic CGM. You say that you are appealing the denial 
of the authorization for the glucose freestyle 2. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria for coverage of a CGM as the records show that the enrollee only used insulin once a day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the receiver for therapeutic CGM have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a receiver (monitor), dedicated, for use 
with therapeutic continuous glucose monitor (CGM) system (K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve outpatient treatment. You say that the enrollee's life is in danger without the 
proper treatment. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because this provider is out-of-network with the Plan and the enrollee can be treated within the Plan 
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 
outpatient treatment to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the enrollee's ability to regain 
maximum function is seriously jeopardized. The appellant says that the requested device is medically 
necessary. The Plan denied your request. The Plan says the enrollee has not been hospitalized within the last 
year and does not meet the guidelines for coverage of the requested device. 
 
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 CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of patients with congestive heart failure. The clinical study on which FDA approval was based showed 
improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was 
implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. 
Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this patients clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept intraosseous basivertebral nerve destruction 
procedure at L5 and S1 vertebral bodies. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested treatment fills a gap for 
patients who do not receive adequate relief from traditional conservative methods and don't have instability to 
indicate fusion is the appropriate treatment. You say that the enrollee has tried and failed conservative 
treatment without relief. You say that the Intracept procedure received initial FDA clearance in the summer of 
2016 which means the procedure is safe and effective. The Plan denied your request. The Plan says the 
requested service is considered to be experimental and investigational as it is not widely used and not generally 
accepted for the suggested use as reported in nationally recognized peer-reviewed medical literature. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case.  Our physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. Additionally, there are multiple 
plausible pathologic sources of significant pain generation. Overall, documentation is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support 
actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or 
reasonable. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines.  
  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Intracept intraosseous basivertebral nerve destruction procedure at L5 and S1 
vertebral bodies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the patient needs this medication because he has been 
on it for three years. The Plan denied your request. The Plan says this drug is not covered under the patient's 
medical benefits. 
 
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 Eliquis.  
 Benefits for Eliquis 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis.  
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat and toilet rail for the enrollee. 
 
You asked the Plan to pre-approve a raised toilet seat and toilet rail. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says these items are not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While these items may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat and toilet rail for the 
enrollee.