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

 
We decided that the Plan does not have to pre-approve proton beam radiotherapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that proton beam radiation therapy is medically necessary 
for this patient's condition. He patient has high-risk stage III prostate cancer with extracapsular extension and 
bladder neck invasion. The patient meets Medicare criteria for PBRT under the applicable Medicare policy. 
The Plan denied your request. The Plan says PBRT is not medically necessary because there is not enough 
evidence to show that this type of radiation treatment is more effective or has less side effects than other forms 
of radiation therapy for prostate cancer. 
 
The Plan follows Medicare rules. Medicare rules say that proton beam radiation therapy is only coverable if 
medically necessary and the patient meets all of the criteria as laid out in the rules section of this letter. 
 
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 PBRT is 
not medically necessary in this case. Our physician reviewer found there is insufficient prospective, long-term 
clinical data available to determine whether or not proton beam radiation therapy for prostate cancer is 
superior, inferior, or equivalent to external beam radiation therapy, IMRT, or brachytherapy with regards to 
safety and efficacy. Recent data shows no significant differences in late (years one, two, and three) patient-
reported toxicity outcomes between proton beam therapy and IMRT. The most recent guidelines state that 
PBRT offers no clinical advantage over other forms of definitive treatment. 
 
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 radiotherapy (PBRT).
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 services are necessary for the 
enrollee's continued care needs. The Plan denied your request. The Plan says the enrollee's medical needs are 
being met in the current 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that manual wheelchairs are only covered for certain 
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 a manual wheelchair. Our reviewer says 
that the documentation does not support that the requested device is medically reasonable or necessary. Our 
physician reviewer found the enrollee has a diagnosis of a left foot cuboid fracture with non-weight-bearing 
status. The provided records in this case do not document the enrollee's mobility limitation cannot be 
sufficiently resolved by the use of an appropriately fitted cane or walker or that the enrollee's home provides 
adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is 
provided or that use of a manual wheelchair will significantly improve the beneficiary's ability to participate in 
MRADLs and the enrollee will use it on a regular basis in the home. Therefore, the enrollee does not meet 
criteria for the requested device. 
 
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 manual wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat liner (K0108) and power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve the wheelchair accessories. The Plan denied your request. The Plan says 
these features are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair seat and back cushion codes are all-
inclusive. Use of HCPCS code K0108 or any other HCPCS code to separately bill for added components such 
as the foam blocks, gel packs, air cells, or equivalent material is incorrect coding. Medicare rules also say that a 
power seat elevation feature (E2300) is non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. Per Medicare rules, the requested seat line (K0108) is not separately 
covered, and is included in the wheelchair seating cost. Additionally, the requested power seat elevation feature 
(E2300) is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
seat liner (K0108) and power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee is being offered 
palliative radiation at two sites. The need for IMRT is not justified based on upon quantifiable dosimetric 
measures or a plausible rationale. The American Society for Radiation Oncology (ASTRO) model policy 
emphasizes the need to support IMRT with dosimetry. The use of IMRT is not the standard of care for the 
enrollee's condition and 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 intensity modulated radiation therapy (IMRT).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says that you only 
meet 2 of the 3 criteria points for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable 2023 Evidence of Coverage 
for this case. We asked for this document, but it was not provided to us. Without this information we cannot 
determine that the Plan's coverage rules support the denial in this case, or that the enrollee has been adequately 
notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their denial in 
this case. Therefore, we decided that the Plan has to pre-approve special supplemental benefits for the 
chronically ill (SSBCI).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that you need a home ventilator because you are 
in danger of suffocating. The Plan denied your request. The Plan says your condition can be managed with bi-
level positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS). 
 
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 a home ventilator is not medically necessary. Our physician reviewer found you have chronic respiratory 
failure from chronic obstructive pulmonary disease. 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 with AVAPS capability. The plan has indicated coverage for such a device is 
available upon request. 
 
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: 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 services are necessary for the 
enrollee to be able to return to the baseline at which they were prior to their hospitalization. The Plan denied 
your request. The Plan says when the enrollee is ready to leave the hospital, they can safely receive this care in 
another setting, such as a skilled nursing facility. 
 
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 they are currently 
receiving 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 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the inpatient hospital stay provided from December 
18, 2022, to December 21, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not provided 
a room right away and should not have to pay for this stay. The Plan denied your request. The Plan says that 
the cost share was applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a complete Evidence of Coverage (EOC). Without a 
complete EOC we are unable to determine if the cost sharing amount was applied correctly. Therefore, we 
decided that the Plan has to waive the copayment for the inpatient hospital stay provided from December 18, 
2022, to December 21, 2022.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires therapy services for their 
strength and endurance to improve mobility and balance deficits. The Plan denied your request. The Plan says 
ongoing skilled care can be received in an alternate setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical conditions appear stable on outpatient medications with no 
issues that appear to require a physicians evaluation three or more times per week in a hospital setting. 
Provided medical records do not explain why the intensive inpatient rehabilitation therapy program is 
necessary and why therapy at a lower level of care such as in a long-term care facility or skilled nursing facility 
is not appropriate for the enrollee. The medical records provided do not support in the documentation that the 
enrollee requires the intensive medical care and the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. IRF criteria rules are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy. 
 
You asked the Plan to pre-approve ultrasound-guided radiation therapy. You say that the requested services are 
a medical necessity for you. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 ultrasound-guided radiation therapy. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that ultrasound-guided radiation therapy is a technology for which need has 
not been established by published data or supported by consensus 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 ultrasound-guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound-guided radiation therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer (Vertiflex device). 
 
You asked the Plan to pre-approve the Superion interspinous spacer (Vertiflex device). You say that the patient 
has failed conservative treatment and the requested procedure and device are considered safe and effective for 
the patient's condition. The Plan denied your request. The Plan says the Superion interspinous spacer (Vertiflex 
device) is not supported in medical literature for the long term relief of back and leg pain. 
 
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 Superion interspinous spacer 
(Vertiflex device). Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the Vertiflex device is considered 
experimental/investigational at this time.  More research is needed before this item can be considered medically necessary and reasonable for this patient's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Superion interspinous spacer (Vertiflex device) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer (Vertiflex 
device).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial 
of an IRF admission stating the enrollee needs rehabilitation to regain their strength. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invitae Comprehensive Lipidemia Panel. 
 
You asked the Plan to pre-approve Invitae Comprehensive Lipidemia Panel. The Plan denied your request. The 
Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is not listed in the DEX database as a covered test. Based on 
this information, we decided that Medicare rules for coverage of Invitae Comprehensive Lipidemia Panel have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Invitae Comprehensive 
Lipidemia Panel.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography, abdominal aorta 
and bilateral iliofemoral lower extremity runoff, with contrast material CTA (75635). 
 
You asked the Plan to pre-approve a computed tomographic. You say that this computed tomographic 
angiography is needed to continue your current quality of life. The Plan denied your request. The Plan says the 
medical records do not show you have leg pain with activity (claudication), does not show you have a condition 
with peripheral artery disease (reduced blood flow) in combination with rest pain, tissue death, or a wound 
(critical limb ischemia), and does not show you have completed 3 months of exercise therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 computed tomographic angiography. 
Our reviewer says that the service is not medically necessary this medical Our physician reviewer found the 
records show that there was no intervention planned and only conservative treatments were recommended 
(medication, walking), no ankle brachial index measurements were noted to measure the degree and confirm 
the diagnosis of PAD prior to considering more advanced imaging. There also does not appear to be a full trial of conservative treatments and there was no other indication described that would justify this testing such as a 
wound. 
 
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 computed tomographic angiography, abdominal aorta and bilateral iliofemoral 
lower extremity runoff, with contrast material CTA (75635) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomographic angiography, abdominal aorta and bilateral 
iliofemoral lower extremity runoff, with contrast material CTA (75635).