Persius/hicric huggingface dataset:
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 requested IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. There is not a reasonable expectation that the enrollee 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that you need the service because you have 
pain, and the issue can cause an infection in your mouth. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Extractions and oral surgery 
procedures are limited to one procedure per tooth per lifetime of the member. 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth (D7210) was exhausted on date of service June 16, 2022. Therefore, we decided that the Plan does not 
have to pre-approve extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided on March 15, 2022. 
 
You asked the Plan to pay for home health services. You say that you have provided medical records to support 
the services at issue. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the Plan has denied the services at issue, stating that home health 
facilities require the correct type of bill. The Plan has not provided an explanation of why the type of bill at 
issue is not correct for the enrollee's situation. It is the Plan's responsibility to substantiate its denial with 
evidence. In this case, the Plan's denial has not been substantiated, so we must find in your favor. Therefore, we 
decided that the Plan has to pay for home health services provided on March 15, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Alimta (J9305) and administration (96409) provided on 
May 2, 2022. 
 
You asked the Plan to pay for the chemotherapy services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 chemotherapy services. Our reviewer 
says that the requested drug, Alimta, is not medically necessary. Our physician reviewer found the Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. There was no literature from Medicare approved cancer journals 
submitted for review. Therefore, the reviewer found that the requested drug is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the chemotherapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for the Alimta (J9305) and administration (96409) provided on May 2, 2022.
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 inpatient rehabilitation to improve 
your quality of life. The Plan denied your request. The Plan says IRF is not medically necessary, and your 
needs can be met at a lower level of care such as skilled nursing facility (SNF), home health or outpatient 
therapy. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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 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: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair and accessories (K0005, 
E0971, E0973, E0978, E2203, E2211, E2213, E2603, K0108). 
 
You asked the Plan to pre-approve an ultra-lightweight wheelchair and accessories. You say that the requested 
wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says the request 
for an ultralight weight manual wheelchair does not meet medical necessity criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 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 ultra-lightweight wheelchair and 
accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation does not support that the enrollee is a full-time wheelchair or requires specialized fittings such 
as axle configuration, wheel camber or seat/back angles which cannot be accommodated by a K0001-k0004 
manual 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 an ultra-lightweight wheelchair and accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair and accessories (K0005, 
E0971, E0973, E0978, E2203, E2211, E2213, E2603, K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient care at the current hospital and can remain there until ready for transfer to a 
lower level of care. 
 
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 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 the 
enrollee is 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lead wires, pair (code A4557) provided on March 29, 2022. 
 
You asked the Plan to pay for lead wires, pair. The Plan denied your request. The Plan says proof of delivery 
did not include an order number or details to corroborate the delivery ticket submitted. The proof of delivery is 
not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, which support medical necessity for the supplies 
provided in this case. The proof of delivery is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for lead wires, pair 
(code A4557) provided on March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from the 
admission to a LTACH. The Plan denied your request. The Plan says that the coverage criteria has not been 
met. 
 
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 that the enrollee appears to still be somewhat unstable and requires short-term 
additional acute care services that can safely be administered at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current 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 LTACH services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the F1 Heme testing provided on January 28, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this is not medically 
necessary. 
 
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 pay for the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the F1 Heme test is a proven medically necessary covered benefit for comprehensive genomic 
profile (CGP) testing for cancer to identify potential targeted therapy options in beneficiaries with a diagnosis 
of Acute Myeloid Leukemia (AML}, Myelodysplastic Syndromes (MDS), Myelodysplastic 
Syndromes/Myeloproliferative Neoplasms (MDS/MPN), and Myeloproliferative Neoplasms (MPN). The 
requested testing is 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 the testing have been met. Therefore, we decided that the Plan has to pay for the 
F1 Heme testing provided on January 28, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Armour Thyro 90MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says Armour Thyroid is a self-administered drug and does not fall under 
Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Armour Thyro 90MG 
tablet.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device. 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record provided includes a magnetic resonance imaging (MRI) that 
shows less than moderate foraminal and central canal stenosis. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve avelumab (used with axinitib as subsequent line 
therapy) (CPT code J9023). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the documentation does not support that the enrollee has an accepted 
medical indication for the use of Bavencio with axitinib. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the requested use of Bavencio (avelumab) (used with axinitib as subsequent line therapy) is not FDA-
approved for the enrollees diagnosis. The use supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve avelumab (used with axinitib as subsequent line therapy) (CPT code J9023).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from October 1, 2022, 
forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 no longer qualifies for SNF coverage. You do not have documented skilled 
nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be 
required to establish a maintenance program or to prevent deterioration of your 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from October 1, 2022, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on March 21, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the date of service billed 
does not match the date the specimen was collected (January 10, 2020). Based on this information, we decided 
that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for genetic testing (81479) provided on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (CPT code(s): 64636 and 
64635). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the Medicare rules have not been 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 the facet joint injections. Our physician 
reviewer found the enrollee had no relief from the last set of injections. It is not appropriate to repeat a failed 
block. The request is not medically reasonable or 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 the facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections (CPT code(s): 64636 and 64635).