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

 
We decided that the Plan has to pre-approve the continuation of inpatient mental health care from May 19, 
2022, and forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that the requested 
continuation of inpatient mental health care from May 19, 2022, and forward is medically necessary. The Plan 
denied your request. The Plan says that the requested continuation of inpatient mental health care from May 19, 
2022, and forward is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, it is the plans responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plans 
failure to obtain records that are within the plans control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the continuation of inpatient mental health care. 
Therefore, we decided that the Plan has to pre-approve the continuation of inpatient mental health care from 
May 19, 2022, and forward.  
 
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 continued rental for a CPAP device (CPT code 
E0601RR). 
 
You asked the Plan to pre-approve the CPAP device. You say that you were ill and could not breathe on it at 
night. You state you were not able to cough with it on either. The Plan denied your request. The Plan says you 
have used the CPAP 9% (nine percent) of the time for greater than four (4) hours per night since starting 
therapy and there are no office notes showing improvement with sleep related breathing problems. 
 
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 CPAP device. Our physician 
reviewer found continued coverage of CPAP is considered not medically necessary because you have been 
unable to use the device enough for it to be effective, or to meet minimum Medicare requirement of at least 
70% of days with at least four (4) hours per day. The compliance report covering February 15, 2022, through 
May 15, 2022, shows only 9% of days with at least 4 hours of use. Compliance issues were addressed in a 
medical visit in February but did not help. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued rental for a CPAP device (CPT code E0601RR).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis, open, SI joint, including obtaining bone 
graft, including instrumentation, when performed (CPT code 27280), the allograft, morselized, or placement of 
osteopromotive material, for spine surgery only (CPT code 20930), and autograft for spine surgery only 
(includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same 
incision (CPT code 20936). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because your records show your provider did 
not include three (3) physical exam tests that cause sacroiliac joint pain, you have tried and failed six (6) 
months of non-surgical treatment including medication for inflammation and at least one of the following: 
physical therapy or injection of the sacroiliac joint for inflammation and pain or radiofrequency rhizotomy. The 
Plan states there is no documentation of previous sacroiliac joint injection that provided at least 50% relief. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of recent and adequate physical therapy (PT) or an injection that 
provided more than 70% pain relief in the SI joint. 
 
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 the arthrodesis, open, SI joint, including obtaining bone graft, including instrumentation, 
when performed (CPT code 27280), the allograft, morselized, or placement of osteopromotive material, for 
spine surgery only (CPT code 20930), and autograft for spine surgery only (includes harvesting the graft); local 
(eg, ribs, spinous process, or laminar fragments) obtained from same incision (CPT code 20936).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 14 Day reader device (CPT code 
K0554). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the Medicare rules 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 enrollee is not using insulin. Based on this information, we 
decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the FreeStyle Libre 14 Day reader device (CPT code K0554).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath test for possible bacterial overgrowth (91065). 
 
You asked the Plan to pre-approve breath test. You say that the requested service should be covered due to the 
enrollee's medical history. The Plan denied your request. The Plan says the breath test is not covered for 
diagnosing small bowel bacterial overgrowth. 
 
The Plan must follow Medicare rules. Medicare rules say that Lactulose breath hydrogen for diagnosing small 
bowel bacterial overgrowth is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of breath test have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
breath test for possible bacterial overgrowth (91065).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live in a town home without anyone to care for 
you and you are unable to navigate up the stairs. You say that you function at bare minimum with a walker 
which prohibits everyday function. The Plan denied your request. The Plan says your records do not show that 
you meet criteria for IRF admission, and you can safely receive the services you need in other settings. 
 
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 that you have no complex nursing or rehabilitation needs. While you 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. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings. 
 
You asked the Plan to pre-approve compression stockings. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings are noncovered because they 
do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative treatment and is 
a good candidate for Vertiflex. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because Vertiflex 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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence-based medical guidelines and peer-reviewed literature do not fully support this 
spinal decompression device over the gold standard of lumbar laminectomy. There is a lack of large-volume, 
long-term, peer-reviewed outcome studies to support the use of this device for the enrollee's condition. There is 
no compelling rationale or extenuating circumstance noted to support the necessity of this procedure as an 
exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 additional transportation miles. 
 
You asked the Plan to pre-approve additional transportation miles. You say that you need more than 50 miles 
approved every time you need transportation. You say that your appointment tomorrow is 61 miles away. You 
also say that you will change plans if you are not transported. The Plan denied your request. The Plan says your 
benefit only allows 50-miles trips. The Plan also says that you have exceeded your 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 Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 11 additional transportation miles.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) receiver 
(K0554) and related supplies (K0553). 
 
You asked the Plan to pre-approve the CGM receiver and supplies. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the member does not use insulin with at least three 
daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
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, 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 the CGM 
receiver and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) receiver (K0554) and related supplies (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services (CPT code 99214) 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 urgently needed. 
The Plan denied your request. The Plan says your records received do not indicate that you have an emergent 
or urgent medical condition or are in need of specialized service(s) that are not available in-network. The Plan 
states 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 office services (CPT code 99214) to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the enrollee has suffered from this 
condition for several years and has failed several months of conservative approaches to treatment. You say that 
you recommend this minimally invasive procedure when conservative treatment has failed a safer alternative to 
a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says the Vertiflex Superion 
procedure is considered investigational and 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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and 
efficacy. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that you are receiving therapy five times a week and 
that should qualify you for the SNF services. The Plan denied your request. The Plan says authorization 
because the SNF care is not medically necessary.  
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 SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs that require skilled nursing services, including the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment. There are identifiable skilled therapy service needs that require skilled therapy services, including 
the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide 
medically necessary and reasonable treatment. You do not require skilled nursing or therapy services daily. As 
a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Euflexxa.  
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 Euflexxa. Our reviewer says that the 
enrollee does not meet criteria for the requested Euflexxa. Our physician reviewer found the record indicates 
that the enrollee has osteoarthritis of the knee.  The record does not indicate that the enrollee has failed a trial 
of conservative nonpharmacologic therapy.  The record indicates that x-rays of the knee are ordered and does 
not include primary source documentation that confirm the diagnosis of osteoarthritis. The elements of the 
coverage criteria are not satisfied.  The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While you 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. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.