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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have 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 patient was admitted for weakness, back pain, and bacteremia. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the patient has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable 
expectation that this patient 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 ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that it is easier to go to this provider. The Plan 
denied your request. The Plan says the services can be safely rendered in-network. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-light wheelchair (K0003). 
 
You asked the Plan to pre-approve an ultra-light wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says there is no physician written order and the plan previously authorized a 
lightweight custom manual chair to meet your needs. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-
approve an ultra-light wheelchair (K0003).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided you only require short-term additional acute 
care services that can safely be administered at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 wig. 
 
You asked the Plan to pre-approve a wig. You say that you lost your hair from Covid-19. The Plan denied your 
request. The Plan says a wig is not a benefit of your health plan. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Imfinzi, Cisplatin and Gemcitabine. 
 
You asked the Plan to pre-approve Imfinzi, Cisplatin and Gemcitabine. You say that this drug regimen is 
medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says 
that there are other treatment options that would be more appropriate based on Medicare guidelines. 
 
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 Imfinzi, Cisplatin and Gemcitabine. 
Our reviewer says that the requested drugs are medically reasonable and necessary for the enrollee's condition. 
Our physician reviewer found the enrollee has been diagnosed with metastatic gallbladder cancer. The 
requested use of Imfinzi, Cisplatin and Gemcitabine is not FDA-approved for the enrollee's diagnosis. 
However, the use of Imfinzi, Cisplatin and Gemcitabine is supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. Specifically, the compendium or article that 
supports the use of this drug regimen is found in the National Comprehensive Cancer Network NCCN 
Guidelines Version 1.2022: Hepatobiliary Cancers. The documentation supports that the requested drugs are 
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 that 
Medicare rules for coverage of Imfinzi, Cisplatin and Gemcitabine have been met. Therefore, we decided that 
the Plan has to pre-approve Imfinzi, Cisplatin and Gemcitabine.  
 
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 (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria. 
 
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 and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection services. 
 
You asked the Plan to pre-approve epidural steroid injection services. You say that these injection services are 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injection services should be 
performed in conjunction with conservative treatments and that the patient should be part of an active 
rehabilitation program, home exercise program or functional restoration program. 
 
We looked at the file and Medicare rules. In this case, there is no evidence provided that the patient is part of 
an active rehabilitation program, home exercise program or functional restoration program. Based on this 
information, we decided that Medicare rules for coverage of epidural steroid injection services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve second opinion visit. You say that your doctor does not return your calls and 
you would like a second opinion from outside of the Plan. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you 
can receive a second opinion from an in-network specialist. 
 
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 
a second opinion visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee will need inpatient 
admission after surgery. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the record does not document that the treating physician has a reasonable 
expectation of a length of stay spanning 2 or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture services (D5214). 
 
You asked the Plan to pre-approve mandibular partial denture services. You say that this dental care is 
medically necessary at this time and cannot wait. The Plan denied your request. The Plan says the benefit for 
this service has been exhausted based on contract rules. 
 
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. The Plan covers mandibular 
partial denture services once every five years.  
 
We looked at this physician's review, the file, and Medicare rules. In this case, this service was last received in 
May 2018. At this time, the benefit has been exhausted as five years have not passed since the denture services 
were received. Based on this information, we decided that the Plan's rules for coverage of mandibular partial 
denture services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
mandibular partial denture services (D5214).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular revascularization. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has documented palpable 
pedal pulses and ankle-brachial indices (ABIs) of 1.32 and 1.10 on the right and left, respectively. She is 
recently underwent what appears to be ablation of her saphenous veins. The coverage and performance of these 
procedures is predicated on the absence of significant peripheral artery disease, as it would not have been 
appropriate to ablate her saphenous veins if she had significant peripheral artery disease. The plan for bilateral 
lower extremity arterial intervention is not matched with a satisfactory assessment of the enrollees current 
symptoms. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovascular revascularization.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the progressive lenses (V2781 x2) and polycarbonate 
or equal lenses (V2784 x2) provided on December 16, 2021. 
 
You asked the Plan to pay more for the lenses. You say that you made an appointment because you were 
having problems with your vision and wanted to know if anything was wrong with your eyes. You also say that 
you are a diabetic and had blurry vision and irritated eyes. The Plan denied your request. The Plan says the 
maximum allowed under your benefit was exceeded. 
 
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 supplemental eyewear every year. 
 
We looked at the file and the Plan's rules. The record shows that the total for these services was $428, the 
allowed $200 was paid by the Plan, and you are responsible for the remaining balance of $228. Based on this 
information, we decided that the Plan's rules for coverage of the lenses have not been met. Therefore, we 
decided that the Plan does not have to pay more for the progressive lenses (V2781 x2) and polycarbonate or 
equal lenses (V2784 x2) provided on December 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve facet joint RFA services. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that an initial thermal radiofrequency ablation of 
cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically 
reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary 
diagnostic medial branch blocks, with each one providing a consistent minimum of 80% sustained relief of 
primary (index) pain. 
 
We looked at the file and Medicare rules. In this case, the record does not document a consistent minimum of 
80% sustained relief after previous medial branch blocks. Based on this information, we decided that Medicare 
rules for coverage of facet joint RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint radiofrequency ablation (RFA) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve back surgery services including L5-S1 fusion revision, 
L4-S1 fusion, possible L4-5 transforaminal lumbar interbody fusion. 
 
You asked the Plan to pre-approve back surgery services. You say that the requested back surgery services are 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage for these services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve back surgery services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 70-year-old female being treated for post-laminectomy 
syndrome; fusion of the spine; and other spondylosis of the lumbar region. She presented with constant, severe lower back pain. Gait is unsteady due to the pain. The exam reveals normal range of motion and 5/5 strength 
maintained in the bilateral upper and lower extremities. Strength is intact. 3+ patellar reflexes are noted. The 
gait is unsteady. 
 
However, detailed documentation is not evident regarding dynamic flexion/extension films in order to 
potentially assess the amount of movement (instability) at the requested surgical level. Detailed documentation 
is not evident regarding potential impending/inevitable temporary intra-operative instability. Additionally, 
detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less 
invasive conservative care measures. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines. Therefore, the requested 
L5-S1 fusion revision, L4-S1 fusion, and possible L4-5 transforaminal lumbar interbody fusion, in this case, 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 back surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve back surgery services including L5-S1 fusion revision, L4-S1 fusion, possible L4-
5 transforaminal lumbar interbody fusion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a primary rhinoplasty (30410). 
 
You asked the Plan to pre-approve a primary rhinoplasty. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested procedure have not been met because the procedure is cosmetic in this case. 
 
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 a primary rhinoplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the procedure coded 30410 is not primarily cosmetic in this case. However, the 
available documentation does not support that the requested procedure is medically reasonable and necessary 
for the enrollee in this case as the enrollee's symptoms improved significantly with medications. 
 
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 primary rhinoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a primary rhinoplasty (30410).