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

We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair and accessories. 
 
You asked the Plan to pre-approve an ultra-lightweight manual wheelchair and accessories. You say that the 
requested items are medically necessary for the enrollee to get the exercise that is needed to be functional as a 
paraplegic. You say that the enrollee's doctor has recommended that he have a manual wheelchair. You say that 
a manual wheelchair is also needed in order for the enrollee to get to locations that cannot be reached by a 
motorized wheelchair. The Plan denied your request. The Plan says the enrollee already has a motorized 
wheelchair. The Plan says that the requested wheelchair would be secondary and not for full-time use. 
 
The Plan follows Medicare rules. Medicare rules say that ultra-lightweight manual wheelchairs are covered 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 an ultra-lightweight manual wheelchair 
and accessories. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer 
found the documentation does not reveal that the enrollee is a full-time manual wheelchair user. The 
documentation does not reveal that the enrollee is unable to perform mobility related activities of daily living 
(MRADLs) in the home with his current wheelchair. The documentation does not reveal an objective detailed 
neuromuscular exam of the patient by a licensed/certified medical professional. The documentation does not 
reveal objective findings on a physical exam that supports that this enrollee must require individualized fitting 
and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat 
and back angles, and which cannot be accommodated by a K0001 through K0004 manual wheelchair. The 
documentation does not reveal that the requested wheelchair will be used in the home and significantly 
improve MRADLs in the home.

Our physician reviewer found that an ultra-lightweight manual wheelchair is not medically 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 ultra-lightweight manual wheelchair and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair and 
accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve BRCA testing. You say that you have extensive family history of cancer and 
can no longer afford the out-of-pocket cost for this testing. The Plan denied your request. The Plan says the 
denial of authorization for this testing is correct, because you have no personal history of cancer, so this testing 
is considered non-covered screening. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA genetic testing is not covered for testing 
of individuals with no personal history of certain types of cancer.  
 
We looked at the file and Medicare rules. This testing is not being requested due to a personal history of 
cancer; therefore, it is considered non-covered screening. Based on this information, we decided that Medicare 
rules for coverage of BRCA testing have not been met. Therefore, we decided that the Plan does not have to 
pre-approve BRCA genetic testing.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided from  
December 16, 2020, through December 31, 2020. 
 
You asked the Plan to pay for skilled nursing facility services. You say that the enrollee was not in hospice on 
these dates of services. The Plan denied your request. The Plan says original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the member's terminal condition. The 
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of 
election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers 
attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 11, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for skilled nursing 
facility services provided from December 16, 2020, through December 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. You say that *** The Plan denied your request. The Plan says the 
enrollee does not have documented bone metastases, and the enrollee has not tried and failed pamidronate or 
zoledronic acid. 
 
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 Xgeva. Our reviewer says that  Our 
physician reviewer found that the requetsed use of Xgeva is not FDA-approved for th eenrollee's diagnosis. The 
notes do not mention bone metastases or osteoporosis. The requested use is not supported by one of the major 
drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed 
as not indicated, not supported or not recommended in any of the compendia. The documentation does not 
support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided t hat 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires SNF care as he is not strong 
enough to return to his senior living facility until he gets some rehabilitation. The Plan denied your request. 
The Plan says that 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 SNF care. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs, though close monitoring in light of the recent diagnosis of coronavirus is reasonable.  
The enrollee does have documented skilled therapy needs.  Daily skilled services are required to establish a 
maintenance program and/or to prevent deterioration of the enrollee's 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 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 skilled nursing 
facility (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 continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that you have neuropathy which 
makes lancing your finger excruciatingly painful to the extent that you are no longer capable of monitoring 
your glucose levels. The Plan denied your request. The Plan says rules for continuous glucose monitors have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous 
glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (K0554).
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 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 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 require the intensity of services provided at an IRF. 

Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553). 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that this is medically necessary. The 
Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0554, K0553).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Inspan). 
 
You asked the Plan to pre-approve Inspan procedure. You say that a long-term study demonstrated improved 
outcomes in patients who underwent this procedure. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because there is insufficient evidence of the efficacy of this procedure. 
 
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 Inspan procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found interspinous process distraction devices remain 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 Inspan procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an interspinous spacer device (Inspan).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an upcoming magnetic resonance imaging 
(MRI). 
 
You asked the Plan to waive the coinsurance for an MRI. You say that you need to get this test but you cannot 
afford this coinsurance. The Plan denied your request. The Plan says this coinsurance applies to all diagnostic 
radiology services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance, up to $75 for diagnostic radiology services.  
 
You have been asked to pay 20% coinsurance, up to $75 for an MRI. MRIs fall within the diagnostic radiology 
services benefit category.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for an upcoming magnetic resonance imaging 
(MRI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100). 
 
You asked the Plan to pre-approve the additional transportation. You say that you would like additional trips to 
be approved because you are completely out of covered trips. The Plan denied your request. The Plan says your 
benefit does not cover more than 10 one-way trips per plan year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of up to 10 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation beyond the Plan's 12-
trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to 
get to your physical therapy appointments. The Plan denied your request. The Plan says the requested number 
of trips will exceed the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The Plan provided documentation 
showing that at the time of the request you had 9 remaining trips in your routine transportation benefit. The 
additional 40 requested trips will exceed this benefit. Based on this information, we decided that you will 
exhaust the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan 
does not have to pre-approve additional routine transportation beyond the Plan's 12-trip limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0120). 
 
You asked the Plan to pre-approve the additional transportation. You say that you are in need of more rides to 
continue seeking adequate care. The Plan denied your request. The Plan says this request exceeds the benefit 
limits set in the subscriber agreement. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of up to 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0120).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the percutaneous discectomy procedure. 
 
You asked the Plan to pre-approve the percutaneous discectomy procedure. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says the requested procedure is 
experimental/investigational. 
 
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 percutaneous discectomy procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found percutaneous discectomy remains 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 percutaneous discectomy procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the percutaneous discectomy procedure.
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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the Plan. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.