Persius/hicric huggingface dataset:
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 an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says based on Medicare guidelines, LTACH services do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case the enrollee was admitted with shortness of breath in the setting 
severe pulmonary hypertension. The record indicates that the enrollee has had a complicated hospital course 
including cardiorenal syndrome and still requires acute care services. The enrollee continues to receive acute 
care services and these have not been denied. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. The elements of 
the coverage rules are not 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 an epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found the enrollee has not had imaging or an adequate trial of conservative therapy. Therefore, the 
request is deemed 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met.  Specifically, you have not requested acupuncture treatment due to a diagnosis of chronic low back pain. 
Therefore, we decided that the Plan does not have to pre-approve acupuncture treatments.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo, Oxaliplatin, Fluorouracil, Diphenhydramine 
Hcl, Dexamethasone sodium phosphate, and Leucovorin calcium. 
 
You asked the Plan to pre-approve Opdivo, Oxaliplatin, Fluorouracil, Diphenhydramine Hcl, Dexamethasone 
sodium phosphate, and Leucovorin calcium. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Opdivo, Oxaliplatin, Fluorouracil, 
Diphenhydramine Hcl, Dexamethasone sodium phosphate, and Leucovorin calcium. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has progression of disease on 
immunotherapy and continuation of nivolumab (Opdivo) would not be indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo, Oxaliplatin, Fluorouracil, Diphenhydramine Hcl, Dexamethasone 
sodium phosphate, and Leucovorin calcium have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Opdivo, Oxaliplatin, Fluorouracil, Diphenhydramine Hcl, Dexamethasone sodium 
phosphate, and Leucovorin calcium.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve the SSBCI benefit. You say that you feel you should be eligible for this 
benefit. The Plan denied your request. The Plan says the requirements for the SSBCI benefit have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefit have not been met. Specifically, we have confirmed that you do not have a need 
for Intensive Care Management or high risk for hospitalization. Therefore, we decided that the Plan does not 
have to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external insulin pump (E0784). 
 
You asked the Plan to pre-approve an external insulin pump. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an external insulin pump (E0784). 
have been met. Specifically, the available medical records do not discuss the need for a replacement for your 
current external insulin pump. Therefore, we decided that the Plan does not have to pre-approve an external 
insulin pump (E0784).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not indicated for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested home ventilator is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has chronic hypoxic respiratory failure from chronic obstructive pulmonary disease. 
The documentation does not contain sufficient detailed information to justify the treatment selected. The 
enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average volume-
assured pressure support capability.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Orthovisc (J7234) injection (20610). 
 
You asked the Plan to pre-approve the injection. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the requested services are not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations is considered medically reasonable and necessary if the patient 
has failed at least three months of conservative therapy. 
 
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 injection. Our reviewer says that the 
requested Orthovisc injection is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate the enrollee has tried and failed at least 3 months of conservative therapy. The 
reviewer found that the enrollee has failed to respond to aspiration of the knee when effusion is present and 
intra-articular corticosteroid injection therapy when inflammation is a significant component of their symptoms 
and intra-articular corticosteroids are not contraindicated. Therefore, the reviewer found that the requested 
Orthovisc injection 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Orthovisc (J7234) injection (20610).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee needs to have aggressive therapy in a safe 
manner prior to surgery. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drugs. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. The record does not document a sufficient 
medical rationale that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred step one alternative. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99213) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visits. You say that your primary care physician (PCP) left the 
practice. You say that you need a new one for your dizzy spells. You say that you need an appointment as your 
medication is running out. You also say that the requested provider is listed as a PCP on the website. The Plan 
denied your request. The Plan says the requested provider is not in network. The Plan also says that the 
requested provider is not listed on the Plan's website. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there are 
network primary care providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the 
Plan does not have to pre-approve office visits (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser cataract removal surgery. 
 
You asked the Plan to pre-approve laser surgery. You say that you feel that the services should be covered 
because your Ophthalmologist told you that you need cataract surgery for both eyes. The Plan denied your 
request. The Plan says under Medicare guidelines, only traditional cataract surgery will be covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. Under either method, Medicare will cover and pay for the cataract removal and insertion of a 
conventional intraocular lens." While traditional cataract surgery is fully covered by most private medical 
insurance and Medicare, blade-less cataract surgery requires patients to pay out-of-pocket for the portion of the 
procedure that insurance does not cover. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of laser surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve 
laser cataract removal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostatic arterial embolization (37242). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are a Jehovah Witness and cannot 
get a blood transfusion, therefore this procedure is needed instead of the regular prostate TURP surgery. The 
Plan denied your request. The Plan says prostatic arterial embolization for treatment for benign prostatic 
hypertrophy is still experimental and investigational because the effectiveness has not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve prostatic arterial embolization (37242).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) (77523). 
 
You asked the Plan to pre-approve PBRT. You say that the enrollee presented with rectal bleeding, bloating 
and abdominal pain. The enrollee has tried previous locally destructive treatments. Given his clinical 
complexity, this should be approved without delay. The Plan denied your request. The Plan says the requested 
PBRT does not meet the requirements for approval. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was diagnosed with locally advanced invasive adenocarcinoma of the rectum in 
August 2022. Imaging on September 8, 2022, revealed a circumferential rectal mass in the mid and high 
rectum. A CT scan of the chest abdomen and pelvis showed a liver mass suspicious for metastatic cancer. The 
NCCN Guidelines Version 3.2022 Rectal Cancer states that radiotherapy should be delivered in a highly 
conformal manner. The techniques can include 3D conformal radiation therapy, intensity-modulated radiation 
therapy (IMRT), or stereotactic body radiation therapy (SBRT). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Radiation Therapy (PBRT) (77523).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care beyond October 20, 
2022. 
 
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee has been making good 
progress and cutting the rehabilitation program will be detrimental to her health. The Plan denied your request. 
The Plan says the enrollee does not require skilled daily therapy or nursing in an inpatient setting, and the 
enrollee's needs can be met at a lower level of care.  
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 the continued SNF care. Our reviewer 
says that the continued SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee was seen in the hospital for a hip fracture that was 
treated surgically. She was discharged to a SNF for rehabilitation on October 3, 2022. As of October 14, she 
required standby assistance for bed mobility, minimal assistance for transfers, and minimal assistance for 
walking up to 30 feet.  
 
The enrollee currently does not have any documented skilled nursing needs or skilled therapy needs. Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
the enrollees 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 the continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing facility (SNF) care beyond October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom cushions (E2609 and E2617) and plastic side 
guards (K0108) for an approved manual wheelchair. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these features are 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 only equipment that is primarily medical in nature is 
covered. The rules also state that a custom cushion is covered when there is a comprehensive written evaluation 
by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), 
which clearly explains why a prefabricated seating system is not sufficient to meet the beneficiarys seating and 
positioning needs. 
 
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 wheelchair accessories. Our 
reviewer says that the requested features are not medically necessary. Our physician reviewer found the plastic 
side guards are not primarily medical in nature and are non-covered. The enrollee has no spasticity and custom 
foot plates are included. The enrollee does not have a pressure ulcer and has cured her previous pressure ulcer. 
She does not require a uniquely designed cushion. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve custom cushions (E2609 and E2617) and plastic side guards (K0108) for an 
approved manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Transmitter 
 
You asked the Plan to pre-approve a Dexcom G6 Transmitter. You say that the transmitter should be covered. 
The Plan denied your request. The Plan says the medical records submitted do not establish that the requested 
device is reasonable and necessary. 
 
 
 
 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 EOC confirms that in order to get the non-preferred diabetic 
supply, you can have your doctor send in a request for this supply as durable medical equipment (DME). The 
documentation submitted shows that the requested transmitter is not a DME supplier of the Plan. Based on this 
information, we decided that Medicare rules for coverage of a Dexcom G6 Transmitter have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 Transmitter