Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) with a rheumatologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have been seeing the requested provider for 
several years and you get 2 shots once per month. You have missed January and now February is due. The Plan 
denied your request. The Plan says you must use network providers to get your medical care and services. The 
Plan can safely provide the requested service 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 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 
an office visit (99205) with a rheumatologist to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bronchoscopic lung reduction surgery. 
 
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 severe chronic 
obstructive pulmonary disease (COPD) with emphysema. The records are insufficient to establish medical 
necessity of the requested procedure. The bronchoscopic lung reduction is not reasonable or medically 
necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bronchoscopic lung reduction surgery.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 Keytruda. Our reviewer says that the 
services are medically necessary. Our physician reviewer found treatment was continued until disease 
progression, development of unacceptable toxic effects, or it is the physician or patient's decision to discontinue 
use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical eye exam and evaluation (92002, 92014), a 
visual field exam (92083), and a refraction (92015) with an ophthalmologist to be provided by an out-of-
network (OON) provider. 
 You asked the Plan to pre-approve ophthalmology services. You say that you need this service right away. The 
Plan denied your request. The Plan says you can be seen and treated by in-network community level providers. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We looked at the file and Medicare rules. The Plan has network providers available who can provide the 
items/services at issue in this appeal. There is no evidence that an INN community level ophthalmologist 
cannot provide an Ophthalmological evaluation for you. You have proptosis and diplopia, and you can be seen 
and treated by community level providers. Based on this information, we decided that Medicare rules for 
coverage of ophthalmology services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a medical eye exam and evaluation (92002, 92014), a visual field exam (92083), and a refraction 
(92015) with an ophthalmologist 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH level of care. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is 
currently unstable for transfer to an LTACH. 
 
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 the enrollee appears to still be somewhat unstable for transfer and requires short-
term additional acute care services that can safely be administered at the current facility until more stable and 
appropriate for a lower level of care. The patient does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet 
stable for transfer and as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is 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 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: 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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's documented nursing, medical and rehabilitation needs 
would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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. The Plan denied your request. The Plan says your records do not 
show that you need daily skilled nursing, the services you require can safely be received at a different setting, 
in home with home health, in residential care, or home with close follow-up with your doctor. 
 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 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. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need aggressive rehab so you can get back to 
your normal self. You say you still need time to recover and have already fallen several times at the previous 
facility. The Plan denied your request. The Plan says that the IRF admission you requested is not supported 
based on the records received. 
 
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 the clinical documentation shows that you have complex functional impairments and active medical 
comorbidities that require inpatient hospitalization with an interdisciplinary approach to rehabilitation care. 
Evaluating therapists and neurosurgery recommend ongoing skilled therapy in an IRF setting thus IRF criteria 
met. 
 
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 
acute 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.
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 enrollee has been getting progressively weaker. 
The Plan denied your request. The Plan says the enrollee does not have complex needs that require a 
coordinated team approach. 
 
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 physician reviewer found 
that the enrollee was hospitalized for left knee septic arthritis. Clinical documentation does not specify any 
complex functional impairments or active medical issues.  The enrollees Parkinsons disease is stable, hypoxia is resolved, and hypertension is also stable. The 
complexity of the enrollees documented nursing, medical and rehabilitation needs would not be expected to 
require an acute inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 2 power wheelchair and accessories K0842, 
E1007, E2311, E2359, E0955, E1028, E2313, E2377, E1028, E1012, E2605 and E2613. 
 
You asked the Plan to pre-approve the power wheelchair. You say that please find all the required clinical 
documentation supporting your appeal request. The Plan denied your request. The Plan says the clinical 
documentation provided does not show medical necessity. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation from the enrollees 
treating medical provider confirming that this enrollee 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 latest provided note from the enrollees medical provider dated January 23, 
2023, stated: "walks with walker." Therapy notes from January 24, 2023, reported the enrollee was walking 
100 feet with a walker with minimum assistance and was contact guard assist for transfers. There is no 
documentation that the enrollees mobility deficit cannot be helped by the use of a walker and there is 
documentation that the enrollee can safely operate a power mobility device. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Group 2 power wheelchair and accessories K0842, E1007, E2311, E2359, 
E0955, E1028, E2313, E2377, E1028, E1012, E2605 and E2613.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on August 11, 
2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and were requested by 
the enrollee's treating physician. The Plan denied your request. The Plan says there is insufficient information 
to support that these services were necessary. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. 
Specifically, the records provided do not include any documentation from the enrollee's treating physician to 
support the medical necessity of these services and clearly document the intent for testing. Therefore, we 
decided that the Plan does not have to pay for definitive drug testing (G0483) provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99242) with an ophthalmologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you cannot get an appointment from network 
providers. You also say that you want to see the requested provider because he has been treating your wife. The 
Plan denied your request. The Plan says you must use network providers to get your medical care and services. 
There are in-network providers available for you to see. 
 
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 
an office visit (99242) with an ophthalmologist to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thoracic spine 
without contrast (72128). 
 
You asked the Plan to pre-approve a CT scan of the thoracic spine without contrast. You say that the requested 
service is medically necessary. The Plan denied your request. The Plan says the service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the thoracic spine without 
contrast. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
record provided does not document any complaint or physical findings attributable to the thoracic spine. The 
provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the 
requested service.  
 
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 CT scan of the thoracic spine without contrast have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thoracic spine 
without contrast (72128).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sodium ferric gluconate complex in sucrose injection. 
 
You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says the 
requested drug is not indicated. 
 
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 requested drug. Our physician 
reviewer found that the enrollee has a ferritin level of 602, a transferrin saturation level of 90, and a transferrin 
level of 192. The levels indicate that the enrollee is not iron deficient. The requested use of the drug is not 
approved for the enrollee's condition. The use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. The documentation does not support that the 
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested drug have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sodium ferric gluconate complex in sucrose injection.
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 enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary. Continued stay at acute hospital until the enrollee is stable enough for discharge to a 
lower level of care has not been denied. 
 
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 enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.