Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kit purchased on June 15, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kit. You say that you were traveling, and the Plan 
card does not work in the United States which is why you had to pay. You also say that it was an emergency, 
and you could not wait to apply for the free tests from the government. The Plan denied your request. The Plan 
says you can use your benefit of over-the-counter (OTC) products provided through the medical plan card to 
purchase COVID-19 home tests. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test kit is an OTC item, however, your Plan offers a supplemental benefit for OTC items. 
Specifically, OTC coverage is only available when using the Plan's medical card. This supplemental benefit 
does not have a provision that covers these tests when purchased out of the service area. Therefore, we decided 
that the Plan does not have to pay for the at-home COVID-19 test kit purchased on June 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you feel you still require rehabilitation 
services to allow you to return home safely. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for approval set forth by Medicare. 
 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 continued 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 you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
Our reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a SNF 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
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 the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that are not 
currently being received but that would be available at the LTACH 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytogenetic study provided on March 24, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that cytogenetic testing is covered for the indications 
established in the applicable NCD. 
 
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 testing. Our reviewer says that the 
requested testing was not medically reasonable and necessary. Our physician reviewer found that The review 
indicate that the enrollee has a diagnosis of abdominal adenopathy. Computed tomography imaging was noted 
for RP/mesenteric lymphadenitis, bile duct dilatation and left ureteral thickening of unclear etiology. He has 
not had a biopsy. The requested testing is not medically reasonable or necessary according to the coverage 
criteria established in the NCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the cytogenetic study provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 powered wheelchair and accessories for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that it is noted that the patient will certainly be at risk 
for future falls without the requested equipment. The Plan denied your request. The Plan says this is 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided there is inadequate documentation that this patient has a 
personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, 
feeding, grooming and bathing in customary locations within the home. The most recent medical visit note with 
her medical provider from 08/04/2022 reports that she requires an "electric wheelchair" for use in the home but 
the physical examination for that same visit reports her gait and stance as "normal." The most recent medical 
visit note with her medical provider from 08/04/2022 reports that she uses a cane or walker in the home but 
suggests the power wheelchair is for use to go longer distances in the community. 
 
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 a group 2 powered wheelchair and accessories for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve) (CPT code 64555). 
 You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Sprint PNS system does not meet the Medicare criteria as it is not an implanted 
peripheral neurostimulator with a trial of implantation showing effective pain control. The Plan states the 
device does not meet the Medicare criteria for reasonable and necessary because the medical record does not 
support that this device meets but does not exceed the enrollee's medical need, and the device has not been 
shown to be effective in the medical literature. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is not adequate evidence of the effectiveness of the Sprint peripheral nerve stimulation 
(PNS) for low back pain. The request 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes 
sacral nerve) (CPT code 64555).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ECG up to 30 days continuous with transmission of 
patient triggered events with review and report by health care professional (CPT code 93229). 
 
You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because your records show you have not 
completed other testing with inconclusive results. 
 
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 physician reviewer 
found there was insufficient documentation to support the medical necessity for a mobile cardiac outpatient 
telemetry (MCOT) monitor in your 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ECG up to 30 days continuous with transmission of patient triggered events with review 
and report by health care professional (CPT code 93229).
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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
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 was admitted for myocardial infraction. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical 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 an electrical connection for a power wheelchair (E2310) 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the electrical connection between the wheelchair controller and one motor, electronic 
accessory (E2310), cannot be 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 pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided records document that the enrollee has "good fine hand movement and normal 
strength" and her wrists and hands are documented as within normal limits. The records thus appear to indicate 
that she has adequate upper extremity strength and function to operate the wheelchair's power options with 
their own switches.  
 
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 an electrical connection for a power wheelchair (E2310) for the enrollee.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 the enrollee was admitted for lower extremity weakness and facial droop. Medical 
problems are stable. 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. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intracept procedure (64628). 
 
You asked the Plan to pre-approve Intracept procedure. You say that the enrollee has tried and failed 
conservative therapy with no relief. You also say that this procedure was approved by the Food and Drug 
Administration (FDA) in 2016. The Plan denied your request. The Plan says that the requested procedure is 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is considered medically reasonable and necessary in this case. Our 
physician reviewer found current moderate to high quality evidence supports the Intracept procedure as a 
reasonable treatment option for those without indication for surgery and having failed conservative treatments. 
The reviewer found that this procedure has been shown to safely provide clinically meaningful reductions in 
pain lasting up to 5 or more years from one procedure. The reviewer found that due to the low-risk nature of 
the procedure comparable to standard nerve root ablation procedures and the much longer duration of benefit, 
the Intracept procedure will be considered reasonable and medically necessary for the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have been met. Therefore, we decided that the Plan has to 
pre-approve Intracept procedure (64628).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Botox (onabotulinumtoxin) injections (J0585). 
 
You asked the Plan to pre-approve the injections. You say that the medication is necessary. The Plan denied 
your request. The Plan says you asked for Botox (onabotulinumtoxina) to be covered for chronic pancreatitis, 
pancreatic duct stricture, steatorrhea, and exocrine pancreatic insufficiency. The Plan states this is not one of 
the conditions that Medicare has determined is covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the injections. Our physician reviewer 
found the review has determined that the requested use of the Botox (onabotulinumtoxin) injections is not Food 
and Drug Administration (FDA)-approved for the enrollees diagnosis. The use in this case, is not supported by 
one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS)-approved medical journal. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Botox (onabotulinumtoxin) injections (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a suction pump, home model, portable or stationary, 
electric, any type, for use with external urine management system (K1006). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need the device because you have a 
urinary incontinence at night and cannot make it from the bed to the toilet. The Plan denied your request. The 
Plan says incontinence supplies are not covered because they are hygienic items that are non-reusable. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a suction pump, home model, 
portable or stationary, electric, any type, for use with external urine management system (K1006).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from IRF services. The Plan 
denied your request. The Plan says that the request 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the complexity of your nursing, medical, and rehabilitation needs requires an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You have significant post operative pain and 
would benefit from the intensity of rehabilitation physician oversight provided in the acute inpatient 
rehabilitation setting. You can tolerate the intensity of rehabilitation therapy provided and would make more 
rapid progress towards being independent with mobility and performing activities of daily living. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
 
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.