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

 
We decided that the Plan does not have to pre-approve Vascepa. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vascepa.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that the requested proton beam radiation therapy (PBRT) is 
medically necessary. The Plan denied your request. The Plan says the requested proton beam radiation therapy 
(PBRT) 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 PBRT. Our reviewer says that the 
requested proton beam radiation therapy (PBRT) is not medically necessary. Our physician reviewer found 
there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other 
forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this 
expensive therapy. The bottom line is that proton therapy for prostate cancer is not experimental, and in fact is 
an accepted treatment approach.  While I do not think that proton therapy is an experimental therapy, any 
potential benefit or detriment of proton therapy over standard Intensity-modulated radiation therapy (IMRT) is 
an investigational question (being pursued in randomized studies- i.e. for intermediate to low risk prostate 
cancer - https://clinicaltrials.gov/ct2/show/NCT01617161 - Proton Therapy vs. IMRT for Low or Intermediate Risk Prostate Cancer (PARTIQoL) ). Other treatment approaches (IMRT +/- IGRT) are also highly effective 
and well tolerated.  Thus, whether proton therapy affords a benefit over other standard approaches 
(IMRT/IGRT) for prostate cancer is an area of investigation and remains controversial.   
 
To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than 
IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy 
on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair with tilt in space and a tray (E1161 
and E0950). 
 
You asked the Plan to pre-approve a manual wheelchair with tilt in space and a tray. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says durable medical equipment 
is not covered when the enrollee is residing in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a manual wheelchair with tilt in space and a tray is being requested for use in a SNF or 
hospital. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair with tilt in 
space and a tray (E1161 and E0950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria for IRF admission. 
 
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 are medically stable and do not need aphysician's supervision 3 times per week 
(at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no acute rehab nursing needs identified or documented. At the current functional level, 
you do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week 
with multidisciplinary approach in an IRF. IRF admission is not medically necessary based lack of medical 
complexity and acute rehab nursing need and high functional level. While you may benefit from continued 
therapy, your rehab needs can be safely provided in a lower intensity 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 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 Accu-Chek Guide test strips, a non-preferred brand 
product. 
 You asked the Plan to pre-approve Accu-Chek Guide test strips. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says you have no medical reason per your 
records why you cannot use the preferred brand test strips covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies. 
 
We looked at the file, the Plan's contract, and Medicare rules. The services at issue are diabetic testing strips 
from a non-preferred brand. The services are available from the Plan's preferred brand. Therefore, we decided 
that the Plan does not have to pre-approve Accu-Chek Guide test strips, a non-preferred brand product.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interspinous decompression spacer procedure 
(22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that you home for a favorable outcome to 
approve this preauthorization request and provide the necessary coverage that the enrollee should be entitled to. 
The Plan denied your request. The Plan says this device is considered experimental and investigative as there is 
insufficient evidence of its safety and efficacy and effects on health care outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at 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 interspinous decompression spacer procedure (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) insertion (33285). 
 
You asked the Plan to pre-approve an ILR. You say that the procedure is medically necessary for the enrollee's 
continued medical care. The Plan denied your request. The Plan says the ILR 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 an ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in the 
enrollees 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 an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) insertion (33285).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast Magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve a breast MRI. You say that the requested breast Magnetic resonance 
imaging (MRI) is medically necessary. The Plan denied your request. The Plan says the requested breast 
Magnetic resonance imaging (MRI) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 breast MRI. Our reviewer says that 
the requested breast Magnetic resonance imaging (MRI) is not medically necessary. Our physician reviewer 
found breast MRI can be used to differentiate surgical scarring and radiation changes from breast cancer 
recurrence in cases where the physical examination and imaging with mammography and/or ultrasound (US) is 
difficult to interpret. However, this enrollee has not had either a mammogram or ultrasound, the former may be 
difficulty after bilateral mastectomies. At this time a breast MRI would not be reasonable or medically 
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 a breast MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a breast Magnetic resonance imaging (MRI).
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 services requested are medically 
necessary. The Plan denied your request. The Plan says the long-term acute care hospital (LTACH) services 
you are requesting do 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 the patient appears to be stable and improving and should only require short-term 
additional acute care services that can be safely completed at the current facility until more 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. There are no services at the LTACH that the patient requires that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you injured your feet over 10 years ago. You 
have only recently been able to walk more than a block due to extreme pain. The orthotics get you through the 
day without needing heavy medication. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
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 is unlikely to be able to tolerate an intensive therapy program. 
 
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 review indicates that the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional chiropractor visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says there has already been 12 visits of routine chiropractor visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found 
that the documentation does not support that the enrollee has subluxation that has resulted in a neuromuscular 
condition for which the requested chiropractic visit is medically indicated per Medicare guidelines. The 
documentation does not support that 12 additional chiropractor visits are likely to provide a significant and 
reasonable expectation of recovery or improvement of function. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional chiropractor visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
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 needed services can be safely provided in other settings, for example, 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 that based on the medical records provided, the complexity of your nursing, medical 
and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical conditions appear stable on outpatient medications with no issues that appear 
to require a physicians evaluation three or more times per week. The records do not explain why the intensive 
inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care such as in a 
skilled nursing facility is not appropriate. There is concern that you would not be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in the IRF, due to guarded rehab potential as 
reported by the therapy staff, as well as weakness, poor endurance, dizziness, and hypotension with therapy. 
The records do not clarify that a slower pace of treatment at the skilled nursing facility level is not appropriate 
in this case. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous infusion, for therapy, prophylaxis, or 
diagnosis (specify substance or drug) (96365) unclassified drug, Ketamine (J3490) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the injection services. You say that you have 30 plus years of treatment for 
depression. You qualified for this treatment after speaking with the doctor who reviewed your history and 
qualified you for this treatment. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. 
 
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 intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug) (96365) unclassified 
drug, Ketamine (J3490) 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 admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that it's unsafe to go home at this point and the 
enrollee needs skilled rehab. The Plan denied your request. The Plan says skilled services can be provided on 
an intermittent outpatient basis, in a long-term care facility, or at the home with home health care services. 
 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 admission. Our reviewer says that 
the requested services are not medically reasonable or necessary. Our physician reviewer found that there are 
no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services 
on a daily basis. The enrollee does 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a remote pacemaker evaluation provided on 
February 14, 2022. 
 
You asked the Plan to waive the copayment for the pacemaker evaluation. You say that you did not see the 
doctor on this date. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient diagnostic tests by a specialty physician.  
 
You have been asked to pay a $20 copayment for the pacemaker evaluation. The pacemaker evaluation falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. 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 waive the copayment for a remote pacemaker evaluation provided on February 14, 2022.