Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service 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 your medical conditions are stable and there are no complex nursing or rehabilitation 
needs. While you may have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services can be 
obtained in a lower level of care. This means admission into an IRF is not medically necessary. 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission is medically necessary. 
The Plan denied your request. The Plan says the 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 provided documentation does not indicate that the enrollee requires services at the 
LTACH that are not available at the acute care hospital where they are 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 inpatient level hospice/palliative care for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there no complicated medications or treatments which cannot be given in the current 
location. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee's son is not comfortable with home hospice. The enrollee requires palliative care, 
supplemental oxygen and pain medication. As these acute care hospitals are licensed to provide the same level 
of care, there is no advantage in moving the enrollee from the current acute care hospital to inpatient hospice. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve inpatient level hospice/palliative care for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Truxima. 
 
You asked the Plan to pre-approve Truxima. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires 
a trial of Rituxan, Ruxience, or Riabni before it will approve Truxima. 
 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 Truxima. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Truxima. Our physician reviewer 
found the Plan requires a trial of Rituxan, Ruxience, or Riabni before it will approve Truxima. The record does 
not show that these would likely be less effective and/or have adverse effects for the 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 Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Truxima.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (CPT code L1820) to be provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there are in-network provider(s) within a reasonable distance from 
your location that can provide this service or item. 
 
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 network 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 
the knee orthosis (CPT code L1820) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for naturopathic services received on November 30, 2021. 
 
You asked the Plan to pay for the services. You say that you would like this to be covered. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for naturopathic services received on November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ibrance 125MG tablet. 
 
You asked the Plan to pre-approve he medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Ibrance is a self-administered drug and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ibrance 125MG tablet.  
 Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: 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. The Plan denied your request. The Plan says the 
enrollee is unstable for transfer. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with a subdural hematoma, acute 
encephalopathy, hyponatremia, and leukocytosis. His hospital course was complicated by acute respiratory 
failure. He is receiving appropriate care at the present acute care hospital. 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 requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2744, V2781, V2750, V2762) 
purchased on January 5, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you are being billed for services which should be 
covered by your Plan. The Plan denied your request. The Plan says they have paid the full $200 allowance for 
these eyeglasses, and you are responsible for the remaining cost. 
 
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. The Plan covers up to $200 for eyewear every year. You are responsible for all costs over and above 
this allowance amount. 
 
We looked at the file and the Plan's rules. The record shows that the total cost of the eyeglasses purchased on 
the date in question was $249.98. The Plan has paid the full $200 allowance, and you are being asked to pay 
$49.98. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2744, V2781, V2750, 
V2762) purchased on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum penile pump. 
 
You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that vacuum erection devices (L7900) are statutorily not 
covered. 
 
The requested device is statutorily not covered by Medicare. Based on this information, we decided that 
Medicare rules for coverage of the pump have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vacuum penile pump.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Erbitux (J9055). 
 
You asked the Plan to pre-approve the Erbitux. You say that the item is medically necessary. The Plan denied 
your request. The Plan says according to the medical records provided and prescriber attestation, the member is enrolled in a clinical trial. Our physician reviewer determined coverage of the requested drug would be 
deemed a routine cost covered by the Medicare Administrative Contractor (MAC). 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the Erbitux as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve the Erbitux (J9055).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve custom fabricated abutment and abutment supported porcelain/ceramic 
crown. You say that you feel that these services should be covered. The Plan denied your request. The Plan 
says these services are not covered under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve the inpatient psychiatric hospitalization. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
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 hospitalization. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment 
beyond the date in question of May 10, 2022 forward and could have been treated in a lesser restrictive setting 
as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and 
were not showing any behaviors or aggression being cooperative and compliant while not showing any acute 
threats to safety. 
 
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 hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the inpatient psychiatric hospitalization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Coenzyme Q10 (CoQ10) testing received on September 17, 
2021. 
 
You asked the Plan to pay for the testing. You say that if you had known this would not be covered, you would 
have opted to not have it. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no coverage for Coenzyme Q10 (CoQ10) 
testing. 
 
Medicare statutorily does not cover this testing Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Coenzyme Q10 (CoQ10) testing received on September 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on March 26, 2021, 
through March 31, 2021. 
 You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the DRG billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 640 with secondary diagnosis code N17.0. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services. Our reviewer 
says that the DRG 640 is not supported by the documentation. Our physician reviewer found acute kidney 
failure with acute tubular necrosis (ATN) was listed as a secondary diagnosis. However, the provided 
documentation does not sufficiently support this diagnosis for this hospital stay. There was no UA results 
suggestive of ATN, and the patient responded to fluids and medication changes quickly with improvement in 
kidney function suggesting no acute kidney failure with ATN.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on March 26, 2021, through March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you do not 
have a plan or intent to harm yourself. 
 
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 continued services. Our physician 
reviewer found that you were admitted to the acute inpatient psychiatric hospitalization with Residual 
Schizophrenia. Based upon review of the records, it was not expected that you would improve in a reasonable 
period of time beyond the dates in question.  You were not showing any dangerousness to self or others. You did not have auditory or visual hallucinations, 
were without aggressive behaviors, and did not show any acute threats of safety. It did 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. You did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or 
abnormal behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the PET with concurrently acquired CT for attenuation correction 
and anatomical localization imaging; skull base to mid-thigh (CPT code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee needs a PET scan to determine if 
these lesions noted on the bone scan are prostate cancer prior to undergoing radical prostatectomy as the 
treatment for metastatic prostate cancer does not typically include radical prostatectomy. The Plan denied your 
request. The Plan says that it is not supported for the first staging (finding extent of disease) of prostate (a gland 
that surrounds the neck of the enrollee's bladder) cancer. 
 
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 PET scan. Our physician reviewer 
found on December 1, 2020, the Food and Drug Administration (FDA) approved the radioactive tracer Gallium 
(Ga) 68 PSMA-11 for use in PET imaging of men with prostate cancer. Under the approval, the tracer can be 
used in PET imaging for prostate cancer that is suspected of having spread to other parts of the body. Ga 68 
PSMA-11 can also be used in men who have been treated successfully for prostate cancer but, because of 
elevated PSA levels, their disease is suspected of having returned. 
 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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve the PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; 
skull base to mid-thigh (CPT code 78815).  
 
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 raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that this item is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this item is considered a convenience item 
and is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.