Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued SNF services. 
 
You asked the Plan to pre-approve continued SNF services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says that continued skilled nursing facility services do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says continued SNF services are not necessary due to the enrollees 
status from August 15, 2022, through August 26, 2022. Records for physical therapy services and occupational 
therapy services provided during this period were not submitted to determine if SNF services were no longer 
required. This means that the Plan has failed to support the denial of continued SNF services. Therefore, we 
decided that the Plan has to pre-approve continued SNF services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart, without 
contrast material (75571). 
 
You asked the Plan to pre-approve a CT scan of the heart. You say that documents were submitted to confirm 
medical necessity. The Plan denied your request. The Plan says the requested procedure does not meet the 
definition of medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the heart. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found while CAC screening improved 
medication adherence, the impact of CAC scoring on behavioral and lifestyle factors, perception of CHD risk, 
and psychosocial effects was not statistically significant compared with baseline. In summary, current evidence 
showing that the use of CAC scores in clinical management of asymptomatic individuals leads to changes in 
patient management or in individual risk behaviors that improve cardiac outputs outcomes is limited and 
inconclusive.  Overall, there is insufficient support in the peer-reviewed literature demonstrating a significant 
benefit of CT imaging of the heart with quantitative evaluation of coronary calcium in guiding optimal 
management of this patient. As such, CT imaging of the heart without contrast material with quantitative 
evaluation of coronary calcium is considered experimental/investigational for the evaluation and management 
of this patient's medical 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 a CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the heart, without contrast material 
(75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the power wheelchair. Our reviewer 
says that the requested power mobility device is not medically necessary. Our physician reviewer found the 
enrollee's home is reported to be inadequately set up to safely use the power wheelchair; it is a two story home 
with inadequate space to maneuver the requested power wheelchair. There is no clear documentation that the 
patient's mobility deficit cannot be helped by the use of a walker, cane or 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 the power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (K0823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision services (92134) provided to you 
on March 2, 2022. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 $25 
copayment for physician services to diagnose and treat diseases and conditions of the eye.  
 
 
 
 
 
 
 Review of the records show that you were provided vision imaging services (92134) on March 2, 2022. You 
have been asked to pay a $25 copayment for the services. The services fall within the vision services benefit 
category. 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 vision services (92134) provided to you on 
March 2, 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 this patient meets the full criteria for an inpatient 
acute rehabilitation stay, as she requires three hours of therapy a day provided by a multidisciplinary team, 
daily provider visits by a physiatrist to consistently monitor her vascular needs, provide adequate paint control, 
and provide medical management. The Plan denied your request. The Plan says based on Medicare guidelines, 
the IRF services requested do not meet the requirements for approval. 
 
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 patient's medical conditions appear stable on outpatient medications with no 
issues that appear to require a physician's evaluation three or more times per week. Our physician reviewer also 
found that provided medical records do not explain why the therapy at a lower level of care such as in a skilled 
nursing facility is not appropriate for the 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires this level of care. The Plan 
denied your request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided at 
a lower 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 member is a 67-year-old female with a medical history including chronic lumbar pain with spondylosis and radiculopathy who was admitted to the hospital for a planned lumbar discectomy and 
fusion of L-4 and placement of interbody spacer L2-5. 
 
In this case, the complexity of the members nursing, medical and rehabilitation needs do not require an acute 
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is no indication that the member would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain her functional status.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has an acute medical diagnosis that 
requires close physician oversight in the inpatient setting with 24-hour nursing care. The Plan denied your 
request. The Plan says this level of care 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 members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy 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 inpatient rehabilitation facility (IRF) admission and services.
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 need IRF care. 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 your nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement. However, there is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain his functional status. You 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion ISS device. 
 
You asked the Plan to pre-approve the Vertiflex Superion ISS device. The Plan denied your request. The Plan 
says the Vertiflex Superion ISS device is not considered 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 the Vertiflex Superion ISS device. Our 
reviewer says that the Vertiflex Superion ISS device is not considered medically reasonable and necessary. Our 
physician reviewer found that the Vertiflex Device is experimental. More research is needed. 
 
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 Vertiflex Superion ISS device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Vertiflex Superion ISS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide 12 additional routine transportation trips for the 2022 plan 
year. 
 
You asked the Plan to provide additional transportation. You say that you need additional transportation to get 
to your appointments. The Plan denied your request. The Plan says your benefit provides up to 24 trips per 
year. Additional trips are not a covered benefit. 
 
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 a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide 12 additional routine transportation trips for the 2022 plan year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
device. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the requested item is a necessity for 
your care. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies have 
not been met. 
 
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 indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre continuous glucose monitor (CGM) device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs the intense therapy the IRF will 
provide. The Plan denied your request. The Plan says the IRF services are 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 rehabilitation 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 he would meet criteria for admission to an acute inpatient rehabilitation facility. 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 his 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Entyvio (vedolizumab) injections to be administered every 6 
weeks. 
 
You asked the Plan to pre-approve the Entyvio injections. You say that the enrollee had been receiving this 
treatment every 8 weeks with partial response. It is felt that more frequent dosing should be attempted prior to 
switching to a different agent. The Plan denied your request. The Plan says that the requested frequency is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Entyvio injections. Our reviewer 
says that the requested medication is considered medically reasonable and necessary at the requested 
frequency. Our physician reviewer found the record indicates that the enrollee has a diagnosis of Crohn's 
disease. The Food and Drug Administration has stated that the requested drug is indicated for the enrollee's 
condition. Neither the Food and Drug Administration nor the Medicare approved drug compendium, DrugDex, 
states that the requested dosing interval of six weeks is not indicated. The medical records provided support the 
use of the requested drug as prescribed. The elements of the coverage criteria are 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 Entyvio injections have been met. Therefore, we decided that the Plan has to 
pre-approve Entyvio (vedolizumab) injections to be administered every 6 weeks.  
 
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.