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

 
We decided that the Plan does not have to pay for the psychotherapy services provided on October 13, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that it was not known that prior 
authorization was required. This should be approved due to medical necessity. The Plan denied your request. 
The Plan says there is no evidence of consultation with the primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that CPs are required to document in the medical 
record that consultation with the primary provider was made or attempted. 
 
We looked at the file and Medicare rules. There is no evidence of a consultation with a primary or attending physician in this case. Based on this information, we decided that Medicare rules for coverage of the 
psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the 
psychotherapy services provided on October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour diabetic test strips and kit. 
 
You asked the Plan to pre-approve Contour diabetic supplies. You say that you need this and your doctor 
advised you to use Contour. The Plan denied your request. The Plan says the denial of authorization for these 
supplies is correct, because you can use supplies from one of the Plan's preferred brands of Accu-Chek or 
OneTouch. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain brands, 
items, and supplies. Your contract with the Plan says that diabetic test strips and monitors must be obtained 
from Accu-Check or OneTouch. 
 
We looked at the file and Medicare rules. The record does not show that you cannot use diabetic test strips and 
monitors from one of the Plans preferred brands. Based on this information, we decided that Medicare rules 
for coverage of Contour diabetic supplies have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Contour diabetic test strips and kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee would benefit from this device. The 
Plan denied your request. The Plan says criteria for CGM are not met as there is no use of insulin. 
 
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 the enrollee does not use insulin 
with at least three daily administrations. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there is no documentation provided necessitating admission to a LTACH. 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 present setting where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 
 
   
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: 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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. The 
enrollee's rehab needs can be met at a lower intensity and alternate setting such as in 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 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
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 you 
do meet the Medicare criteria for SNF care. 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 have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You are reportedly functioning below your baseline following several recent hospitalizations. The 
records do not clearly establish that you have reached a new plateau in function. You do require daily skilled 
therapy on an inpatient basis in a SNF setting to establish a maintenance program and/or to prevent 
deterioration of your condition. Your care needs, as a practical matter, cannot be provided 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
   
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 K3 foot represented by code L5981, a multi-axial 
rotation unit represented by code L5986, and a protective outer surface covering represented by code L5962.  
You asked the Plan to pre-approve codes L5981, L5986, and L5962. You say that the enrollee is a K3 level in 
need of an advance foot to accomplish his goals and to avoid any falls and/or risk of injury. You say that the 
medical records provided support the enrollee's medical necessity. The Plan denied your request. The Plan says 
the records do not indicate that the enrollee is exposed to harsh conditions or engages in extraordinary activities 
that require extra protection from a specialized prosthetic cover. The Plan says that the enrollee has been 
approved for a standard prosthetic coverage that is sufficient for everyday use. The Plan says that the request 
for a K3 foot exceeds the enrollee's need and does not meet the Medicare criteria of reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve codes L5981, L5986, and L5962. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested items exceed the enrollee's medical need. The enrollee has been using a 
K2 foot since 2019. The documentation does not reveal objective physician medical progress reports 
supporting the need for a K3 level foot. The documentation does not reveal physician progress notes that reveal 
why the enrollee's needs cannot be met with a K2 level as he had been using. The documentation does not 
reveal that the enrollee requires an L5962 covering as there is no evidence that he requires specialized 
protection against unusually harsh environmental situations beyond the protection offered by a standard 
prosthetic covering. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes L5981, L5986, and L5962 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a K3 foot represented by code L5981, a multi-axial rotation unit 
represented by code L5986, and a protective outer surface covering represented by code L5962.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve the inpatient psychiatric care. The Plan denied your request. The Plan says 
this request is not medically necessary because the records received show that your condition has improved, 
and you are no longer a threat to yourself or others. 
 
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 pre-approve the inpatient psychiatric care. Our 
reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care 
beyond March 7, 2022. Our physician reviewer found that it is not expected that you will improve in a 
reasonable period of time beyond the date in question as you are not showing any dangerousness to yourself or 
others, auditory or visual hallucinations, or aggressive behaviors. You were compliant and cooperative with 
treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than 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 the inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat therapeutic facet injection services. 
 
You asked the Plan to pre-approve repeat therapeutic facet injection services. You say that the clinical 
documentation provided support the need for the requested injection services. The Plan denied your request. 
The Plan says the enrollee should be moved to radiofrequency ablation (RFA) once medial branch blocks are 
successful. The Plan says that the enrollee refuses RFA despite the results. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are covered when 
medically reasonable and for certain clinical 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 repeat therapeutic facet injection 
services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
documentation sent by the provider, does not support the need for a repeat therapeutic facet injection.  
According to the records submitted, there is no medical reason that the enrollee cannot move forward to an 
RFA.  The requested facet joint injections are not medically reasonable or necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat therapeutic facet injection services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve repeat therapeutic facet injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845) addition to endoskeletal knee-shin system, fluid stance extension, dampening 
feature, with or without adjustability (L5848) addition to lower extremity prosthesis, endoskeletal knee-shin 
system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type 
(L5856). 
 
You asked the Plan to pre-approve the K3 foot and ankle. You say that the enrollee requires a K3 multi-axial 
foot with pylon that will provide stability on uneven ground, the ability to navigate sudden changes in weight 
shifts and balance to prevent falls. The Plan denied your request. The Plan says a prosthesis with K3 foot 
exceeds the enrollee's needs and does not meet the criteria of reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the K3 foot and ankle. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided documentation does not support that the 
enrollee is (or will be) a K3 level ambulator to meet Medicare criteria for the requested K3 foot and ankle 
system. Records document that the enrollee uses a power wheelchair for mobility and will need a cane for 
ambulation even with the requested K3 foot and ankle system; this is not consistent with a K3 functional level. 
 
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 K3 foot and ankle have not been met. Therefore, we decided that the Plan 
does not have to pre-approve addition, endoskeletal, knee-shin system, stance flexion feature, adjustable 
(L5845) addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability (L5848) addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor 
control feature, swing and stance phase, includes electronic sensor(s), any type (L5856).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says that Keytruda is not appropriate for the enrollee's cancer treatment. 
 
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 Keytruda. Our reviewer says that the 
requested drug is medically reasonable and necessary for the enrollee's condition. Our physician reviewer 
found the enrollee has been diagnosed with stage III non-small cell lung cancer - squamous cell type. In 
addition, the enrollee is positive for programmed death-ligand 1 (PD-L1). In this case, Keytruda meets criteria 
for stage III non-small cell lung cancer - squamous with PDL1+ because this is approved for this condition 
according to the FDA label. Molecular testing is not needed for squamous histology. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the nerve destruction by neurolytic agent (64633). 
 
You asked the Plan to pre-approve the nerve destruction by neurolytic agent (64633). You say that you 
attached clinicals for review and an occipital nerve block should be reconsidered. The Plan denied your 
request. The Plan says the coverage criteria has 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 the nerve destruction by neurolytic 
agent (64633). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that CPT code 64633 is used when, a treatment plan 
shows the region (upper, middle, or lower back) and levels of the spine to be treated, no more than two levels 
of the spine will be treated on the same day, and the procedure is planned between the C2-3 (neck) and L5-S1 
(lower back) spinal levels. Our reviewer says that this is not documented in the medical records.  
  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 nerve destruction by neurolytic agent (64633) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the nerve destruction by neurolytic agent (64633).
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. The 
enrollee's rehab needs can be met at a lower intensity and alternate setting such as in 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 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: 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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 daily 
skilled services are not necessary. Our physician reviewer found you do not need skilled therapy services on a 
daily basis. You do not require the necessary services on an inpatient basis, in a skilled nursing facility 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.