Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement socket (L5700) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a replacement socket. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records received do not indicate that the enrollee has an emergent or 
urgent medical condition or needs specialized service(s) that are not available in the network. There are in-
network provider(s) within a reasonable distance from the enrollees 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 
a replacement socket (L5700) to be provided by an out-of-network (OON) provider.
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 you tested for Covid-19 the day before you were 
scheduled to be discharged and your family is unable to care for you. The Plan denied your request. The Plan 
says the SNF services requested do not meet the requirements for approval. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to a medical appointment. The Plan denied your request. The Plan says your benefit only allows 
12 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 56 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
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 the member is not ready to be discharged due to a 
decrease in function. The Plan denied your request. The Plan says the continued SNF services requested do not 
meet the requirements for approval. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 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: 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 requesting admission to an IRF that is 
located closer to family. The Plan denied your request. The Plan says the member does not meet the 
requirements for an IRF admission. 
 
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 you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. 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. 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 inpatient rehabilitation facility (IRF) admission and services.
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 you would like to continue care at this 
facility. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
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 you are presently receiving appropriate services in the acute care setting and do not 
appear to be stable for transfer due to delirium and unresolved plan for nutrition and hydration with dysphagia. 
Continued care in the short-term acute hospital is appropriate until you are stable to transfer to a lower level of 
care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek guide test strips and an Accu-Chek guide 
kit. 
 
You asked the Plan to pre-approve Accu-Chek guide test strips and kit. You say that you have trouble using the 
OneTouch products. The Plan denied your request. The Plan says that only the preferred brand products listed 
in the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic supplies. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek guide test 
strips and an Accu-Chek guide kit.
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 services are medically necessary for the 
enrollee's medical needs. The Plan denied your request. The Plan says We could review alternate settings if 
requested such as a skilled nursing facility, outpatient setting or home health 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 enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that they 
would meet criteria for admission to an acute inpatient rehabilitation facility.  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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81270, 81279, 81339). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested testing will help determine 
whether or not the enrollee has polycythemia and would therefore help direct treatment. The Plan denied your 
request. The Plan says the enrollee does not meet the guidelines for the requested service which does not 
appear 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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for enrollees with erythrocytosis that appears to be secondary, a serum EPO should be used to 
differentiate between primary and secondary erythrocytosis. This enrollee likely has secondary causes of 
erythrocytosis which could be confirmed by serum EPO testing. The review has determined that the 
items/services at issue in this case are not medically reasonable and 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81270, 81279, 81339).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient mental health care provided from May 11, 
2022, through June 26, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the care provided was mediclaly necessary and 
should be reimbursed. The Plan denied your request. The Plan says it was decided to make payment for the 
care up to May 10, 2022. Beyond that time, active inpatient psychiatric treatment was not required. 
 
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 the inpatient care. Our reviewer says that the 
inpatient psychiatric care provided beyond May 10, 2022, was not medically reasonable and necessary. Our 
physician reviewer found the progress notes do not indicate that the enrollee had been aggressive with peers or 
staff on the unit or had had any recent attempt to harm himself as of the last covered date of 05/10/2022. There 
was no indication in the available medical records that the enrollee's psychiatric symptoms could not be 
managed on a less restrictive basis. His mental status and overall functioning were noted to be at baseline. He 
was not exhibiting any other significant symptoms such as mania. He had no acute psychiatric issues that 
would require continued inpatient care. The enrollee has chronic symptoms. The available medical records do 
not support that inpatient care would have changed these symptoms or the enrollee's current condition. The 
beneficiary is chronically impaired due to Unspecified psychosis and the continued inpatient hospital stay was 
not expected to improve the condition in a reasonable period of time. The enrollee did not require inpatient 
treatment from 05/11/2022 through 06/24/2022. 
 
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 care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient mental health care provided from May 11, 2022, through June 26, 2022.
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 member requires an IRF admission to regain 
strength before being discharged home. The Plan denied your request. The Plan says the member does not meet 
the criteria for an IRF admission. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 
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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled therapy needs and the enrollee is functioning at a level with 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Yttrium-90 (Y-90) radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that data supports Y-90 for treatment of 
segment isolated lesions. The Plan denied your request. The Plan says that this type of radiation therapy is not 
needed or effective for the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the requested services. Our physician 
reviewer found that Localized treatment options for liver metastases include resection, cryotherapy, 
radiofrequency ablation embolization (radioembolization or chemoembolization), and stereotactic radiation.  
Systemic therapy is the standard treatment option for patients with liver metastases. 
  
Whole liver radiation is a reasonable approach for palliation, though the toxicity and efficacy are likely inferior 
to Y-90 radioembolization, because the dose used for whole liver radiation is generally sub-therapeutic (due to 
the toxicity with the use of higher whole liver dosing).  In general, radioembolization has a durable response, 
perhaps more so than transarterial chemoembolization (TACE), and tends to be better tolerated than TACE. 
There are innumerable prospective and retrospective studies demonstrating the use of radioembolization for 
metastases for colorectal cancer or hepatocellular cancer. The FDA has in fact approved the use of SIR-
spheres/theraspheres for these indications. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve Yttrium-90 (Y-90) radiation therapy.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bladder sling. 
 
You asked the Plan to pre-approve a bladder sling. You say that the records provided support that at bladder 
sling is medically necessary for treatment of the enrollee's mixed incontinence. The Plan denied your request. 
The Plan says the clinical information provided shows the enrollee has mixed incontinence. The Plan says that 
they did not receive any diagnostic testing results confirming that the enrollee has stress incontinence. The Plan 
says that the notes provided do not document a failure of conservative management. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bladder sling. Our reviewer says that 
a bladder sling is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the record indicates that the enrollee has mixed urinary incontinence.   The record provided is insufficient to establish the medical necessity of the requested service. 
 
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 bladder sling have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bladder sling.