Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve Ocrevus. You say that you believe the requested provider is in-network. The 
Plan denied your request. The Plan says this drug is available for administration from an in-network provider. 
 
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 
Ocrevus to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be 
provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
(G0453) provided on December 19, 2022. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. The Plan denied your 
request. The Plan says experimental/investigational services are not covered. 
 
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 pay for the continuous intraoperative 
neurophysiology monitoring. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that continuous intraoperative neurophysiologic monitoring (IONM) is recommended for patients who are at increased risk of neurological 
injury during surgical procedures. The clinical Intraoperative Neuromonitoring Report in the case file does not 
support that the enrollee in this case was at increased risk of neurological injury during this particular surgical 
procedure. 
 
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 continuous intraoperative neurophysiology monitoring have not been met. 
Therefore, we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology 
monitoring (G0453) provided on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IG-IMRT), 20 
fractions (77014, 77370, 77470). 
 
You asked the Plan to pre-approve IMRT, 20 fractions. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the rules for the special radiation are not met in this case, so Medicare 
cannot cover the special radiation. It is unproven and experimental for your condition. 
 
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 IMRT, 20 fractions. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found IMRT for bone or bone metastases is uncommonly needed for the palliative 
treatment. For this case, while there are planning records, there is no dosimetric rationale for IMRT or 
explanation for why IMRT would be needed over 2D or 3D radiation. The plan comparison shows both plans 
meeting dosimetric constraints, and the plan compared against IMRT appears to only be using AP-PA fields as 
opposed to oblique fields that might shape the dose better. While the IMRT plan lowers the bowel dose, the 
bowel dose is high in the non-IMRT plan because of the beam arrangement and non-standard dose of 40 Gy in 
20 fractions which is not a dose recommended by ILROG for palliation of multiple myeloma. The decision is 
unfavorable for this case as IMRT is not within accepted standards of medical practice for palliation of multiple 
myeloma and the LCD criteria are not met specifying, palliative treatment of metastatic disease where the 
prescribed dose does not approach normal tissue tolerances. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT, 20 fractions have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intensity Modulated Radiation Therapy (IG-IMRT), 20 fractions (77014, 77370, 
77470).
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's needs could be met at a skilled nursing facility. 
 
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 intensive rehabilitation and has shown impaired 
capacity to respond to intensive therapy.  
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 cardiac implantable device (33208). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of prophylactic implantation of a pacemaker in 
this patient with no evidence of symptomatic bradycardia. As such, the evidence provided would not meet 
criteria for pacemaker implant. In summary, there is insufficient documentation to support the medical 
necessity for the requested cardiac pacemaker in this patients clinical management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a cardiac implantable device (33208).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiopharmaceutical localization of tumor, 
inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool 
imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) 
transmission scan for anatomical review, localization and determination/detection of pathology, minimum 2 
areas (e.g., pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more 
days (78832). 
 
You asked the Plan to pre-approve a nuclear medicine test. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested testing. 
 
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 nuclear medicine test. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a SPECT CT is not indicated for workup or follow-up of treatment of prostate cancer, 
including with Pluvicto. According to ASCO guidelines, one or more of these imaging modalities should be 
used for enrollees with advanced prostate cancer, conventional imaging (defined as computed tomography 
(CT), bone scan, and/or prostate magnetic resonance imaging (MRI) and/or next-generation imaging (NGI), 
positron emission tomography (PET), PET/CT, PET/MRI, or whole-body MRI) according to the clinical 
scenario. 
 
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 nuclear medicine test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a radiopharmaceutical localization of tumor, inflammatory process or distribution 
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); 
tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for 
anatomical review, localization and determination/detection of pathology, minimum 2 areas (e.g., pelvis and 
knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days (78832).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the enrollee 
was successfully treated with bilevel positive airway pressure (BiPAP) during a recent hospital stay. The 
enrollee could be treated with a BiPAP machine with average volume assured pressure support (AVAPS) 
capability. The plan has indicated coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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 LTACH services are necessary in order 
of you to get off the ventilator and get the therapy and care you need so you can go back home. The Plan 
denied your request. The Plan says the requested LTACH admission does not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care setting. The Plan has approved ongoing care in the current acute care setting. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for your diagnosis and condition, and can 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 a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the enrollee 
was successfully treated with bilevel positive airway pressure (BiPAP) in the hospital but was then 
noncompliant as an out-patient. The enrollee could be treated with a BiPAP machine with average volume 
assured pressure support (AVAPS) capability. The plan has indicated coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF admission 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an IRF stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for encephalopathy. The enrollees medical problems are stable, and there are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0009 provided on September 6, 2022. 
 
You asked the Plan to pay for procedure code G0009. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0009 is administration of pneumococcal vaccine. We 
find that code G0009 was denied as it was not billed with a 771 revenue code. The claim information shows 
that the services were provided at a rural health clinic. Revenue code 771 is billed for all providers except 
RHCs and FQHCs. Based on this information, we decided that Medicare rules for coverage of the billed service 
have been met. Therefore, we decided that the Plan has to pay for procedure code G0009 provided on 
September 6, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composites (D2392) for tooth #20 and 
#29, and to pay for the gingival irrigation (D4921), and periodontal scaling and root planing (D4341) provided 
by an out-of-network provider on June 9, 2022, and July 26, 2022. 
  You asked the Plan to pay more for the dental services. You say that the dental care was needed due to a gum 
infection. The Plan denied your request. The Plan says the denial of payment for the gingival irrigation is 
correct because it is not covered by the Plan. The periodontal scaling and root planing was not medically 
necessary. You are also responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider.   
 
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 the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says that 
the periodontal scaling and root planing is not medically necessary. Our physician reviewer found that the 
documentation indicates that there was no record of periodontal charting, and the radiographs did not reveal 
areas of bone loss or subgingival calculus accumulation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the periodontal scaling and root planing have not been met. The gingival 
irrigation is not covered under the Plans dental benefit. You have been asked to pay the difference between the 
out-of-network providers charges and the Plans payment for the resin-based composites. 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 pay more for the resin-based composites (D2392) for tooth #20 and #29, and to pay for the 
gingival irrigation (D4921), and periodontal scaling and root planing (D4341) provided by an out-of-network 
provider on June 9, 2022, and July 26, 2022.