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

 
We decided that the Plan does not have to pre-approve transperineal focal laser ablation (TPLA). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this treatment is not a standard of care. 
 
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 the record indicates that you have a diagnosis of localized unfavorable intermediate risk prostate cancer 
(cT1c, GG 3, PSA 6.3 ng/mL). There is insufficient literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service for the enrollee's clinical condition. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules,  of the requested service. The 
elements of the coverage criteria are not satisfied. 
 
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 transperineal focal laser ablation (TPLA).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of perforated gastric ulcer and renal insufficiency. Your medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exercise equipment purchased January 5, 2021. 
 
You asked the Plan to pay for the exercise equipment. You say that you started the purchase in December 2020 
but were not able to complete your purchase until January 2021. The Plan denied your request. The Plan says 
this is not a covered benefit under your plan. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only for programs specified in the Plans Evidence of Coverage. 
 
 
 
 
 
 Though the Plan provides a Wellness allowance for certain health and wellness education programs, exercise is 
not among the items covered by this benefit.  Therefore, we decided that the Plan does not have to pay for the 
exercise equipment purchased January 5, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient hospital stay for gastric bypass revision. 
 
You asked the Plan to pre-approve the inpatient admission. You say that the inpatient stay is medically 
necessary. The Plan denied your request. The Plan says that this procedure can be performed in an outpatient 
setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 inpatient admission. Our reviewer 
says that the documentation supports that the criteria for inpatient care are met in this case. Our physician 
reviewer found a minimum of one acute inpatient stay is considered medically standard and appropriate to 
consider evaluation, treatment for potential acute complications, provide nutritional access and evaluate for 
appropriate nutritional intake. 
 
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 inpatient admission have been met. Therefore, we decided that the Plan has 
to pre-approve an inpatient hospital stay for gastric bypass revision.  
 
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 you are a fall risk, and you need IRF services in 
order to regain your strength. The Plan denied your request. The Plan says the criteria for admission to an IRF 
are not met. You can safely receive the services you need 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 that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast reduction surgery. 
 
You asked the Plan to pre-approve the breast reduction surgery. You say that you would like reconsideration 
because your breasts cause discomfort and back pain. The Plan denied your request. The Plan says this 
procedure is cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast reduction surgery. Our 
reviewer says that the record indicates that you have breast ptosis. Our reviewer found the record provided does 
not indicate that you have tried and failed conservative treatments. The record provided does not indicate that 
the requested procedure is being performed to correct accidental injury or improve functioning of a malformed 
body member. 
 
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 breast reduction surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the breast reduction surgery.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electroencephalogram (EEG). 
 
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 the enrollee has Alzheimer's disease 
and short-term memory difficulty for the past one year. On examination two months ago, he had a normal gait 
and a Mini Mental State Examination (MMSE) score of 22. There is currently insufficient high-quality 
evidence to support routine use of EEG in the setting of Alzheimer's dementia, and it was not clearly stated 
how this test would lead to improved outcomes for the enrollee. Therefore, this request for EEG will be 
considered not 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 an electroencephalogram (EEG).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlisted evaluation and management service (99499) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve unlisted evaluation and management service. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the records received do not indicated that 
there is an emergent or urgent medical condition, or are in need of specialized services that are not available in 
the network. The Plan also says that there are in-network providers within a reasonable distance from the 
enrollee's location that can provide this service or item. 
 
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 
unlisted evaluation and management service (99499) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the patient is currently not on any treatment at this time and has not tried any oral 
bisphosphonate or oral bisphosphonate-containing products. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary. The enrollee has a diagnosis of osteoporosis with high risk of fracture. 
The Food and Drug Administration has stated that the requested drug is indicated for the enrollee's condition. 
The requested medication is a new start. The Plan requires a trial of ibandronate or zoledronic acid before they 
will approve the requested drug. The provided records do not indicate that the enrollee has tried and failed the 
Plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from the Plan's preferred step one alternative. Our physician reviewer found that 
the enrollee's condition does not meet step therapy criteria for Prolia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued infusions to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the continued infusions. You say that you would like reconsideration 
because it is medically necessary for you to continue care with this provider. The Plan denied your request. The 
Plan says you can continue your every four-week infusion with an in-network oncologist. 
 
 
 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 provider at issue in this case is not a network provider with the Plan. 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 continued infusions. Our reviewer says that there is no documentation 
that it is medically necessary for the enrollee to continue care with the out-of-network provider. Our physician 
reviewer found records do not document unique circumstances in this case that would necessitate continued 
care with the out-of-network provider as opposed to care with an equally certified in-network provider. 
 
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 continued infusions have not been met.  
 
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 the continued infusions. Therefore, we decided that the 
Plan does not have to pre-approve continued infusions to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller and accessories (E2311, 
E2377, E2313, E2300). 
 
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 requested expandable controller and related accessories are not medically reasonable 
and 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested accessories are not medically necessary as he does have use of his hands and can operate 
and control the power options using the switches that are included in the basic wheelchair. 
 
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 an expandable controller and accessories (E2311, E2377, E2313, E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) machine 
battery to be rendered by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested item. 
 
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 item at issue in this appeal. We found no exception that would require the Plan 
to pre-approve the item. Therefore, we decided that the Plan does not have to pre-approve a continuous positive 
airway pressure (CPAP) machine battery to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telephone evaluation and management 
service (99442) provided on November 5, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says copayment has been applied correctly to the 
service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each covered telehealth visit or consultation in an outpatient location with a specialist.  
 
 You have been asked to pay a $40 copayment for the telehealth specialist visit provided. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the telephone evaluation and management service (99442) provided 
on November 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical fusion surgery to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve cervical 
fusion surgery to be rendered by the out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne testing provided on December 17, 2021. 
 
You asked the Plan to pay for the testing services. You say that the results were needed for the physician to 
make an informed decision. The Plan denied your request. The Plan says there is no information about the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are limited medical records outside of the test 
results and lung biopsy. There are insufficient records that show the physicians treatment strategy of the 
enrollees condition, and how the results of the testing will impact clinical outcomes. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the FoundationOne testing provided on December 17, 2021.