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

 
We decided that the Plan does not have to pay for wound care supplies provided on August 29, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 03, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
November 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bi-Level Positive Airway Pressure (BiPAP) device 
(E0470), headgear (A7035), chin strap (A7036), replacement face mask (A7031), filter (A7039), humidifier 
(E0562), oral cushion (A7028), nasal pillow (A7029), nasal cushion (A7032), nasal cannula pillow (A7032), 
and filter (A7038). 
 
You asked the Plan to pre-approve a BiPAP and accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare does not cover items that are not 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 BiPAP and accessories. Our reviewer 
says that these items are not medically necessary. Our physician reviewer found that a replacement PAP device 
is not medically necessary. You have obstructive sleep apnea (OSA), diagnosed in 2018 with a sleep study. At 
that time CPAP was ineffective and BiPAP 20/14 was effective. BiPAP was ordered at that time and notes 
indicate that you have a BiPAP device at home. You had another PAP titration study done December 17, 2022, which confirmed that CPAP was ineffective and BiPAP 20/14 was effective. It is unclear from the records 
provided whether you currently have a BiPAP device that is functional. The original device was prescribed less 
than 5 years ago, and therefore is not eligible for replacement. The records do not indicate whether you are 
currently compliant with BiPAP, or having symptoms related to the OSA. 
 
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 BiPAP and accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Bi-Level Positive Airway Pressure (BiPAP) device (E0470), headgear 
(A7035), chin strap (A7036), replacement face mask (A7031), filter (A7039), humidifier (E0562), oral cushion 
(A7028), nasal pillow (A7029), nasal cushion (A7032), nasal cannula pillow (A7032), and filter (A7038).
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. The Plan denied your request. The Plan says an 
LTACH admission 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 the enrollee is improving with current treatment and should only require short-term 
additional acute care services that can safely be administered at the current facility until more appropriate for a 
lower level of care. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous and completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 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 this service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has 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 while the medical record supports a need for physical and/or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not strong enough to perform daily 
functions without the support of daily therapy. The Plan denied your request. The Plan says you do not meet 
the Medicare guidelines for services in a SNF. 
 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 have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist; however, you do not require 
skilled therapy services on a daily basis. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity of 
service criteria for 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 SNF care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 45 intensity-modulated radiation therapy (IMRT) fraction 
treatments. 
 
You asked the Plan to pre-approve 45 IMRT fraction treatments. You say that the records provided support the 
need for the IMRT treatments being requested. The Plan denied your request. The Plan says that the number of 
radiation units being requested is above the recommendations set by medical policy 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 45 IMRT fraction treatments. Our 
reviewer says that the requested IMRT services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the radiation oncologist was unable to develop an optimal plan with 28 fractions 
but was able to do so with 45 fractions. He discussed with a genitourinary (GU) specialist who felt 45 fractions 
was appropriate. 45 fractions in considered acceptable by National Comprehensive Cancer Network (NCCN) 
guidelines and American Society for Therapeutic Radiology and Oncology (ASTRO), American Society of 
Clinical Oncology (ASCO), and American Urological Association (AUA) Evidence-Based Guidelines. 
Treatment with 45 fractions of IMRT would be furnished in accordance with accepted standards of medical 
practice and meet standard medical necessity criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 45 IMRT fraction treatments have been met. Therefore, we decided that the 
Plan has to pre-approve 45 intensity-modulated radiation therapy (IMRT) fraction treatments.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not able to care for yourself, and you cannot 
perform everyday activities alone. You say you have no strength and rehab can give you more strength. 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 have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist; however, you do not require 
skilled therapy services on a daily basis. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity of 
service criteria for 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 SNF care.
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for admission to the 
LTACH have 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 the enrollee appears to be improving with current treatment but is not yet stable for 
transfer and should only require short-term additional acute care services that can safely be administered at the 
current facility. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH would not be clinically advantageous and completion of 
treatment at the current facility is 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 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 a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that you want to continuous monitor your glucose to see 
how medication is affecting you. The Plan denied your request. The Plan says you do not meet criteria for a 
CGM. 
 
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 CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a SNF 
admission. 
 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. This enrollee does not meet severity of illness or intensity of service criteria for 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 SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee has been on Keytruda, and has been 
tolerating treatment well without any significant adverse effect. You also say that the labs reviewed are 
adequate for treatment to proceed with cycle 3 of Keytruda with Temozolomide. The Plan denied your request. 
The Plan says the requested use of Pembrolizumab is not approved as being shown to be medically beneficial 
for the treatment of enrollees with astrocytoma. 
 
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 Keytruda. Our reviewer says that 
Keytruda is not reasonable and necessary for the enrollee. Our physician reviewer found Pembrolizumab as 
monotherapy or in combination with Temozolomide is not Food and Drug Administration (FDA) approved for 
the treatment of glioblastoma or astrocytoma. The use is not supported by the National Comprehensive Cancer 
Network (NCCN) Guidelines, major drug compendia, or phase III trials in the medical literature. Our reviewer 
also found that the use is not reasonable or medically necessary or safe and effective for this enrollee. 
 
 
 
 
 
 
 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this procedure is experimental and is non-covered. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested Vertiflex spacer placement is experimental. More research is 
needed to show safety and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional prosthetic accessories (L5910, L5968, L5972, 
L5962). 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documented physiologic change requiring new prosthetic foot; no irreparable 
change to the foot is documented; no documentation of repairs for the foot is documented. 
 
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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document that the patient's present alignable system and prosthetic foot and ankle have been lost, stolen, irreparably damaged or have reached their reasonable useful lifespan to 
require replacement. The provided medical records do not document that the patient will be exposed to such an 
unusually harsh and difficult environment that the standard prosthetic cover would be inadequate for the 
patient's needs.  
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional prosthetic accessories (L5910, L5968, L5972, L5962).
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 this service is medically necessary. The 
Plan denied your request. The Plan says 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 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. The health plan has approved ongoing care 
in the current acute care 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 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.