Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781) and an addition, endoskeletal 
system, below knee (BK), alignable system (L5910). 
 
You asked the Plan to pre-approve a vacuum socket system. You say that the requested socket system is 
medically necessary. The Plan denied your request. The Plan says the request for advanced features of 
previously approved LE prosthesis does not meet Medicare criteria as reasonable and 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 a vacuum socket system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that the vacuum-assisted socket system and the alignable 
system at issue in this case meet all Medicare criteria for medically reasonable and necessary for the enrollee. 
Although records from the device vendor argue medical necessity of the requested devices, no records from the 
enrollee's actual treating provider clarify why the requested devices are necessary and the most appropriate 
treatment for the enrollee's condition. 
 
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 vacuum socket system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb volume 
management and moisture evacuation system (L5781) and an addition, endoskeletal system, below knee (BK), 
alignable system (L5910).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the enrollee is still in the 
hospital. The Plan denied your request. The Plan says this request is not medically necessary because the 
records show the enrollee does not have abnormal blood pressure or heartbeats that do not get better with 
treatment, trouble thinking clearly which is new and not better with treatment, nor severe electrolyte 
abnormalities. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 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 inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record does not show that admitting physician reasonably expects that 
the enrollee's necessary hospital care will span two midnights. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high intensity focused ultrasound (HIFU) treatment 
(CPT code(s): 55880 and C1889). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is no documentation to support prior radiation therapy and the provider 
acknowledges this is not supported by National Comprehensive Cancer Network (NCCN) guidelines for 
treatment.  
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 the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
Specifically, there is no documentation to support prior radiation therapy and the provider acknowledges this is 
not supported by NCCN guidelines for treatment. 
 
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 high intensity focused ultrasound (HIFU) treatment (CPT code(s): 55880 and C1889).
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 enrollee does 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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for confusion, respiratory failure, and pneumonia. 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, in 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. 
 
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 pneumatic compressor, segmental home model 
without calibrated gradient pressure (E0651) and a segmental pneumatic appliance (E0669) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and appliance. You say that the requested provider 
is the only supplier in your area that supplies this lymphedema pump. The sleeves adjust to your limb size. You 
need to be taught how to use the equipment with a certified medical nurse, which this supplier provides. The 
Plan denied your request. The Plan says the requested provider is not contracted in your Plan's network. 
Medically necessary care is available 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 
a pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and a segmental 
pneumatic appliance (E0669) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that the enrollee does 
not meet the conditions for a stay in an IRF. 
 
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 the enrollee has active hospital complications and would be 
expected to require close medical supervision on an inpatient basis during rehabilitation. Our reviewer also 
found that evaluating therapists recommend intense therapy, such as physical therapy and occupational therapy, 
thus IRF criteria has been met and is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for and office visit, a motion fluoroscopic evaluation, an x-ray 
examination of the esophagus, an x-ray examination of the spine, an x-ray examination of the jaw, an x-ray 
examination of the teeth, and an x-ray examination of the upper gastrointestinal tract provided on April 27, 
2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for and office visit, a motion fluoroscopic evaluation, an x-ray examination of the 
esophagus, an x-ray examination of the spine, an x-ray examination of the jaw, an x-ray examination of the 
teeth, and an x-ray examination of the upper gastrointestinal tract. You say that the member required these 
services due to medical necessity. The Plan denied your request. The Plan says this is a non-contracted provider 
who performed services to the member without prior authorization from the Plan. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for and office visit, a motion fluoroscopic evaluation, 
an x-ray examination of the esophagus, an x-ray examination of the spine, an x-ray examination of the jaw, an 
x-ray examination of the teeth, and an x-ray examination of the upper gastrointestinal tract provided on April 
27, 2022, 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 SNF admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission. 
 
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 
enrollee does not meet criteria for SNF admission. Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide 
medically necessary and reasonable treatment. Records do not document the need for intravenous medications, 
new tube feeding, or ostomy care or daily complex wound care or respiratory care. Based on the medical 
records provided this enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and 
judgment of a qualified therapist are required to safely and effectively provide medically necessary and 
reasonable treatment. Based on the medical records provided there is no documentation that daily skilled 
services are required. The enrollee is walking household distances with two quad canes with stand-by 
assistance and is stand-by assist for transfers and stairs. Provided records do not document a significant decline 
in the enrollees functional status to necessitate daily inpatient skilled therapy services. Based on the medical 
records provided there is no documentation that the enrollee requires the services on an inpatient basis, only in 
a skilled nursing facility setting. Records do not support that continued services in the acute inpatient 
rehabilitation facility are not appropriate until the enrollee is stable to discharge to a lower level of care such as 
home or an assisted living facility with home health 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. You asked the Plan to pre-approve a power scooter. You say that you are unable to walk short distances. The 
Plan denied your request. The Plan says you do not meet the conditions. 
 
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 a power scooter. Our physician 
reviewer found that you have a medical history of diabetes with polyneuropathy and a right Achilles tendon 
strain. There is no documentation that you have 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. There is no documentation that your mobility deficit cannot be helped by the use of 
a walker or manual wheelchair. Therefore, the request is not 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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that no authorization was obtained due to no order 
being placed. You also say that it was medically necessary to provide this service to the patient. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider and there is no 
referring provider involved in these services. The Plan also says that they did not authorize any services for this 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on May 31, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the 
Intracept procedure is considered an experimental/investigational 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 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 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 this enrollee does not require ongoing skilled nursing services with the specialized 
skill, knowledge and judgment of a skilled professional nurse  to safely and effectively provide medically 
necessary and reasonable treatment in a SNF beyond the last covered date. The enrollee's functional level does 
not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist 
to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
require skilled nursing or skilled therapy on a daily basis or as a practical matter in a SNF. 
 
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 pre-approve six (6) office visits and treatment with a urologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits and treatment. You say that you disagree with the denial and 
have submitted clinical documents to support medical necessity. The Plan denied your request. The Plan says 
the enrollee must use network providers to get her medical care and 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 six (6) office visits and treatment with a 
urologist to be provided by an out-of-network (OON) provider.