Persius/hicric huggingface dataset:
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 you are appealing with 
supporting records. The Plan denied your request. The Plan says this is 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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this is not the community standard of care for such skin cancer lesions. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric tricycle. 
 
You asked the Plan to pre-approve an electric tricycle. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is for use outside of the home and therefore, is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an electric tricycle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you qualified last year and now you do not. 
You say that you need access to the additional benefits to help improve your quality of life. You also say that you are at high risk of hospitalization but have been taking steps to not have to go due to high exposure risk. 
The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
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 an expedited reconsideration 
stating the enrollee currently meets IRF admission criteria. The Plan denied your request. The Plan says the 
IRF admission is not medically necessary and does not meet criteria for an IRF level of care. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and two or 
more power seating system motors (E2311), a harness (E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors, a harness and an expandable controller. You say that these items will improve 
the enrollee's quality of life. The Plan denied your request. The Plan says that these items do not meet criteria 
for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that these features are covered when the criteria in the 
rules section of this letter are met. 
 
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 an electronic connection between 
wheelchair controller and two or more power seating system motors, a harness and an expandable controller. 
Our reviewer says that these features are medically necessary. Our physician reviewer found that the enrollee is 
non-ambulatory and requires a power wheelchair for mobility and performing her basic daily activities. She 
cannot perform pressure relief independently due to weakness and requires a power wheelchair with power tilt and recline for adequate pressure relief and positioning. The enrollee also requires power elevating leg rests for 
positioning. The complexity of seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. The expandable controller with harness and electronic connection are necessary to operate the 
group 3 power wheelchair base and the power tilt and recline and power elevating leg rests via a joystick. The 
enrollee is hemiplegic due to her stroke and requires the power options to be operated via a joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection between wheelchair controller and two or more power 
seating system motors, a harness and an expandable controller have been met. Therefore, we decided that the 
Plan has to pre-approve an electronic connection between wheelchair controller and two or more power seating 
system motors (E2311), a harness (E2313) and an expandable controller (E2377).  
 
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 ventilator. 
 
You asked the Plan to pre-approve a 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
EPAP (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with average 
volume-assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and 
failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drugs, intravenous (IV) pamidronate or zoledronic acid. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Xgeva 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 Xgeva.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guidance Radiation Therapy (IGRT) (G6002). 
 
You asked the Plan to pre-approve IGRT. You say that the enrollee has a history of non-small cell carcinoma 
of the lung. The IGRT is medically necessary for her treatment. The Plan denied your request. The Plan says 
the enrollee has a history of stage IV lung cancer. Use of IGRT in this situation cannot be considered standard. 
There is not enough medical evidence to show that this type of radiation treatment is effective to treat the 
enrollee's cancer. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found generally, IGRT is used when there is a need to escalate the dose, and or use tight margins to 
adequately treat the target while sparing surrounding normal tissue. With whole brain radiation (including 
treatment of leptomeningeal disease as is the case for this enrollee), it is not standard to use IGRT. Enrollees 
are generally treated with a somewhat rigid aquaplast mask with relatively low dose, and with simple beam 
arrangements such that the need for IGRT is not plausible even when covering the cribriform plate. It may be 
that the April 18, 2023, letter is in error in that it states that the course of treatment has changed to potentially 
curative course which is generally not the case for leptomeningeal disease (and if she does not have 
leptomeningeal disease then why is IGRT being requested for whole brain radiation?) There is not a plausible 
need for IGRT. The decision is unfavorable for IGRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guidance Radiation Therapy (IGRT) (G6002).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a consultation. You say that the service should be covered. The Plan denied 
your request. The Plan says there are in-network providers available to perform this 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 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 
a consultation to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 10 visits of physical therapy (PT) services. 
 
You asked the Plan to pre-approve the PT visits. You say that if you do not have the extra units you will need 
to have a joint replacement surgery and you are an active runner. The Plan denied your request. The Plan says 
the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found the additional requested therapy generally is not accepted as specific and 
effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy 
and the documentation does not reveal that you require the ongoing unique skills of a professional therapist to 
safely and effectively provide treatment, that the services can be safely and effectively be performed only by a 
therapist, or by or under the supervision of a therapist. You have had home exercise instruction and can 
transition to an independent home program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional 10 visits of physical therapy (PT) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care of any kind, including home 
health and/or skilled nursing facility (SNF) care, is not adequate to help the enrollee return to their prior level 
of function and improve their life. The Plan denied your request. The Plan says the requested IRF admission is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional status.  
The enrollee can receive further services at a 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an 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 an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the service should be covered. The Plan denied 
your request. The Plan says there are in-network providers available to perform this 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 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
enrollee does not meet the 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 does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services. 
 
You asked the Plan to pre-approve neuropsychological testing evaluation services. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing evaluation services 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 neuropsychological testing evaluation 
services. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the enrollee has had difficulty with Anxiety Disorder 
Unspecified (F41.9). The documentation shows this physician asking the question what is wrong with the 
enrollees sleep and memory. Based on review the documentation, this testing is intended to diagnose and 
characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain 
including detection of neurologic disease based on quantitative assessment of neurocognitive abilities, 
differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of 
central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous 
system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or 
management strategies among individuals with neuropsychiatric disorders utilizing criteria from the LCD, it is 
difficult to tell what neuropsychological testing would do to help with treatment or improve outcome of this 
enrollee. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing evaluation services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve neuropsychological testing evaluation services.