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

 
We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy procedure. 
 
You asked the Plan to pre-approve a percutaneous laminotomy/laminectomy procedure. 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. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a percutaneous laminotomy/laminectomy procedure have not been met. Specifically, medical 
records were not provided. Without this documentation, medical necessity is not able to be established. 
Therefore, we decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy 
procedure.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
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. 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 were admitted for gout flare of the left ankle. 
Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: 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 would be a better fit for the enrollee. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information we have about the 
enrollee's condition; the enrollee does not meet 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 that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental hygiene services (D0001) provided on March 17, 
2021, through October 6, 2021. 
 
You asked the Plan to pay for the dental hygiene services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says a corrected claim is needed. 
 
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 the dental hygiene services (D0001) 
provided on March 17, 2021, through October 6, 2021. have been met. Specifically, the claim was submitted 
with an invalid procedure code. There is insufficient information to determine what CPT code D0001 
represents or if it is a covered service per your contract with the Plan. Of note, the record indicates that the Plan 
attempted to reach your provider to obtain the missing codes to facilitate the processing of the claim, but were 
advised that the provider cannot provide this information and that only you can obtain it. Therefore, we decided 
that the Plan does not have to pay for the dental hygiene services (D0001) provided on March 17, 2021, 
through October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a male vacuum erection system. 
 
You asked the Plan to pre-approve the system. You say that this is needed for mental and emotional health. The 
Plan denied your request. The Plan says this is not a Medicare-covered benefit. 
 
The Plan must follow Medicare rules. The rules say that vacuum erection devices (L7900) are statutorily not 
covered. 
 
The requested item is not covered under any circumstances. Based on this information, we decided that 
Medicare rules for coverage of the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a male vacuum erection system.
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 need rehabilitation. The Plan denied your 
request. The Plan says the denial of authorization for IRF service is correct. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need 
physical and/or occupational therapy, there is no documented need for an intensive rehabilitation care. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) home COVID-19 tests purchased 
on January 16, 2022. 
 
You asked the Plan to pay for the home COVID-19 tests. You say that you do not have any local options for 
COVID-19 tests without making an appointment with your provider, so you feel these tests should be covered. 
The Plan denied your request. The Plan says these over-the-counter tests are not covered by Medicare, and they 
are not on the Plan's list of eligible items under your supplemental benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. The Plan offers 
a supplemental benefit to cover some OTC items which are not covered by Medicare. For that reason, the 
Plan's rules apply in this case. 
 
Though the Plan offers a supplemental benefit for OTC items in excess of Medicare coverage, the requested 
home COVID-19 tests are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the over-the-counter (OTC) home COVID-19 tests purchased on January 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says this drug is not eligible 
for coverage under the Part B benefit. 
 
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 Eliquis.  
 
 
 Benefits for Eliquis 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 an out-of-network referral for a plastic and 
reconstructive surgeon. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says network providers must be used for medical care. 
 
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 out-of-network referral for a plastic and reconstructive surgeon.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Armodafinil 250mg tablets. 
 
You asked the Plan to pre-approve Armodafinil. You say that Armodafinil is medically necessary. The Plan 
denied your request. The Plan says this drug is not Eligible for Coverage under the Part B medical benefit. 
 
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 Armodafinil 250mg tablets.  
 
Benefits for Armodafinil 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says 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 the skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found daily skilled services 
are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollees 
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 the skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Flow Cytometry provided on November 30, 2021. 
 
You asked the Plan to pay for the Flow Cytometry. You say that the Flow Cytometry provided on November 
30, 2021, was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet 
criteria for the Flow Cytometry provided on November 30, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Flow Cytometry. Our reviewer says that 
the enrollee did not meet criteria for the Flow Cytometry provided on November 30, 2021. Our physician 
reviewer found the enrollee was evaluated by a hematologist for macrocytosis. The enrollee's mean corpuscular 
volume (MCV) and mean corpuscular hemoglobin (MCH) were elevated. On November 30, 2021, it is 
documented that the enrollee was frail, with a low appetite. The review of systems was generally negative. 
Flow cytometry testing was performed on November 30, 2021. The clinical documentation does not support 
that the enrollee had a medical condition for which flow cytometry would be covered. 
 
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 Flow Cytometry have not been met. Therefore, we decided that the Plan 
does not have to pay for the Flow Cytometry provided on November 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colorectal cancer screening (G0121) provided on 
December 20, 2021. 
 
You asked the Plan to pay for the screening. You say that the previous colonoscopy from 2018 was not 
complete, and the enrollee should be allowed to have another screening covered. The Plan denied your request. 
The Plan says this service was billed as a colonoscopy for a low-risk individual. The Plan only covers 
screenings for those who are low risk once every ten years (120 months). It has not been ten years since the 
enrollee's last colonoscopy screening. 
 
The Plan follows Medicare rules. Medicare covers colorectal cancer screening tests. For people not at high risk 
of colorectal cancer, the Plan covers one screening colonoscopy every ten years (120 months), but not within 
48 months of a screening sigmoidoscopy. 
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, the CPT Code Manual definition of code G0121 is colorectal cancer 
screening; colonoscopy on individual not meeting criteria for high risk. 
 
We looked at the file and Medicare rules. The service in this case was billed as a colorectal cancer screening 
for an individual who does not meet high risk criteria. The documentation shows that the enrollee received a 
previous colorectal cancer screening, also billed with code G0121, in December of 2018. The Plan covers one 
colorectal cancer screening every ten years for individuals who do not meet the criteria for high risk. Therefore, 
we decided that the Plan does not have to pay for the colorectal cancer screening (G0121) provided on 
December 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm (J0172). 
 
You asked the Plan to pre-approve Aduhelm. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 Aduhelm. Our reviewer says that 
Aduhelm is not medically necessary. Our physician reviewer found this drug is not FDA approved for the 
enrollee's condition. Use of Aduhelm for treatment of Pompe disease is not supported in the Medicare-
approved Compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aduhelm (J0172).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an axial rotation unit (L5984) and a shank foot system 
(L5987) for a lower extremity prosthesis (Proteor Shockwave) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the socket is no longer fitting and is causing pain. 
The Plan denied your request. The Plan says there is no documentation of weight loss in the records provided. 
 
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 the request for a replacement foot exceeds the patient's medical needs. The patient was issued a foot in 
2021 and the documentation does not support objective measurements of weight loss that require a replacement 
foot. 
 
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 axial rotation unit (L5984) and a shank foot system (L5987) for a lower extremity 
prosthesis (Proteor Shockwave) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. Although the enrollee is 
very limited functionally, provided records do not document a significant decline in the enrollees functional 
status compared to his recent baseline to necessitate daily inpatient skilled therapy services. There is no 
documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the home with home health care or in a long-term care facility on a part time basis appear 
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 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 Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections or require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).