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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has stabilized medically and is ready for discharge from the 
hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The 
enrollee is medically stable and can receive further rehab services at a lower level of care. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without 
any acute exacerbations of chronic medical problems. The physical function is at or near her baseline and she 
can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services. 
 
You asked the Plan to pre-approve the services. You say that this is medicallu necessary. The Plan denied your 
request. The Plan says continued monitoring of a stable condition without an endpoint is not medically 
necessary and not covered. 
 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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been approved. Records 
document the enrollee has been educated on her disease process, proper diet and medications. No medical notes 
from the enrollee's treating physician are provided documenting an order or need for additional skilled nursing 
services. Records do not document the need for intravenous medications, new tube feeding or ostomy care or 
daily complex wound 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health care services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that admission to a SNF is medically necessary. The 
Plan denied your request. The Plan says that SNF care 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 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require daily skilled nursing or skilled therapy services. You are 
medically stable and can receive further rehabilitation services at lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage of tumor treatment field therapy 
with an electrical stimulation device (E0766). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for coverage. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided, there is no documentation that the continuation of tumor 
treatment field therapy for glioblastoma multiforme with an electrical stimulation device (E0766) (Optune) at 
issue in this case is reasonable or necessary. The records do not document the patient is continuing to use and is 
benefiting from the tumor treatment field therapy as required. The records document that the patient's "life is 
better/easier off Optune" and the medical treatment plan is to "stop Optune 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of tumor treatment field therapy with an electrical stimulation device 
(E0766).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric services provided by an out-of-network 
provider on July 19, 2022, to July 21, 2022. 
 
You asked the Plan to pay for inpatient psychiatric services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says medical necessity has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
  
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 pay for inpatient psychiatric services. Our reviewer 
says that the medical criteria for inpatient psychiatric services have not been met. Our physician reviewer found 
the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the 
date in question of July 19, 2022, forward and could have been treated in a lesser restrictive setting as he was 
not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not 
showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to 
safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient psychiatric services provided by an out-of-network provider on July 19, 
2022, to July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic continuous glucose monitor system (K0554) supply allowance used with a therapeutic CGM device 
(K0553). 
 
You asked the Plan to pre-approve the Freestyle Libre 2. You say that the enrollee is already on this device and 
is paying out of pocket when it is a covered supply. The Plan denied your request. The Plan says the request is 
not medically necessary as the records do not show that the enrollee meets all of the Medicare criteria. 
 
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 Freestyle Libre 2 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic continuous glucose monitor system (K0554) supply allowance used with a therapeutic CGM device 
(K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myopro device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro is not known to be effective, based on scientific evidence, professional standards and 
expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Myopro device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, 
E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's upper limb strength and function are adequate for the member to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the power seat elevation is not covered by Medicare. The enrollee has sufficient upper 
extremity function to manage the standard switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) of the lumbar spine 
provided on June 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied 
your request. The Plan says authorization was not obtained prior to services being rendered. 
 
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 magnetic resonance imaging (MRI) of the lumbar 
spine provided on June 3, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee surgery. 
 
You asked the Plan to pre-approve knee surgery. You say that the records provided support the need for the 
requested surgery. The Plan denied your request. The Plan says the enrollee's diagnosis has not been confirmed 
by imaging. 
 
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 knee surgery. Our reviewer says that 
knee surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found 
detailed documentation is not evident regarding diagnostic imaging supporting pathology. Despite the provider 
indicating that there are meniscal tear findings on exam, this is not corroborated by (any available) imaging 
studies. Moreover, the objective findings noted on recent exams reveal patellar compression tenderness. There 
are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
(degenerative) clinical setting. 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 knee surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found in this case, the record indicates 
that you have chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that 
you had been treated with bilevel positive airway pressure (BiPAP). The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a BiPAP machine. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging; skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET scan of the body. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
Additionally, the NCCN guidelines do not support PET/CT for surveillance of lung cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that they will cover one PET scan to determine the 
initial level of cancer treatment needed for an enrollee.  
 
We looked at the file and Medicare rules. The records show that you have been on surveillance for 6 years and 
there has been no antitumor treatment since the surgery in November 2019. Medicare rules confirm that the 
enrollee is covered for a PET scan to determine the initial level of cancer treatment. The records also show the 
PET scan was requested as a routine surveillance. Medicare does not cover routine surveillance for PET scans. 
Based on this information, we decided that Medicare rules for coverage of a PET scan of the body have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography 
(PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical 
localization imaging; skull base to mid-thigh (78815).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's needs can be met at a lower level of care such as home, long-term care 
facility, or other outpatient setting. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has stabilized medically and is ready for discharge from the 
hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The 
enrollee is medically stable and can receive further rehab services at a lower level of care. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without 
any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near her baseline 
and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services from a licensed 
professional counselor (LPC). 
 
You asked the Plan to pre-approve these services. You say that you have not been able to find a counselor that 
takes your insurance. The Plan denied your request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that a licensed professional counselor (LPC) is not eligible 
to participate in Medicare. 
 
We looked at the file and Medicare rules. The requested provider is a licensed professional counselor. This 
provider type is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
outpatient mental health services from a licensed professional counselor (LPC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter/crutch substitute. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit, as there is insufficient clinical literature demonstrating 
safety and effectiveness. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is inadequate documentation in the current peer-reviewed medical literature or the provided 
medical records that the requested knee scooter/crutch substitute meets Medicare criteria for being safe and 
effective and medically reasonable and necessary for the Medicare population or this patient. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a knee scooter/crutch substitute.