Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been diagnosed with functional moving 
disorder, which has affected your body being in constant movement. You say that you cannot take care of 
yourself and are in need of intense therapy and treatment to regain function. The Plan denied your request. The 
Plan says IRF is not medically necessary. You could receive care in another setting such as SNF, outpatient 
setting or home health 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. Our 
physician reviewer found while the medical record supports a need for physical 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is high risk for hospital 
readmission and potentially life-threatening exacerbations. The Plan denied your request. The Plan says the 
request is not medically necessary because the records show that the enrollee had improvement in breathing 
when using a bilevel positive airway pressure (BiPAP) device with supplemental oxygen. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease and obesity hypoventilation 
syndrome. The record indicates that the enrollee was successfully treated with BiPAP.  The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional home health physical therapy services. 
 
You asked the Plan to pre-approve additional home health physical therapy services. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health physical therapy 
services. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the documentation shows that the enrollee has improved 
with therapy to the point of being able to walk 400 feet with a single point cane with modified independence. 
After the physical therapy treatments already provided, records do not support that the complexity of the 
enrollee's conditions are such that the skills of a professional therapist are required to achieve further 
improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program 
appears appropriate at this point. Provided records do not document any acute or unstable medical conditions or 
injuries which would necessitate any further skilled physical therapy visits beyond what have already been 
approved. Records document the enrollee has been educated on a home exercise program. No medical notes 
from the enrollee's treating physician are provided documenting an order or need for additional skilled therapy 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health physical therapy services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 16 additional home health physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repair and parts replacement. 
 
You asked the Plan to pre-approve power wheelchair repair and parts replacement. You say that the items in 
dispute are medically necessary. The Plan denied your request. The Plan says the requested repair is not cost 
effective and not medically necessary. The Plan says that the enrollee should submit a request for an 
appropriate new wheelchair and covered accessories. 
 
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 power wheelchair repair and parts 
replacement. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee's current wheelchair is more than 5 years old, 
and the proposed repair is over $7,000. The proposed cost of the power wheelchair repair and parts replacement 
is 50% more than the average cost of a new wheelchair. The current wheelchair is more than 5 years old, out of 
warranty and eligible for replacement. Replacement is more cost effective than repair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair repair and parts replacement have not been met. Therefore, 
we decided that the Plan does not have to pre-approve power wheelchair repair and parts replacement.
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 an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says based on the additional information available, the 
request does not meet the Medicare or health Plan coverage criteria. 
 
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 in this case the enrollee was admitted with altered mental status in the setting of 
hypoxic and hypercapnic respiratory failure, ischemic cardiomyopathy, and acute kidney injury. The record 
indicates that the enrollee is still acutely ill and requires ongoing acute care services. The enrollee continues to 
receive acute care services and these have not been denied. The medical record does not indicate that the 
enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.  
The elements of the coverage rules are not satisfied.  
 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 4, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit You say that a pre-authorization is not required for this procedure. 
The Plan denied your request. The Plan says the enrollee must receive care from a network 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 an office visit 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 an office visit these 
items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on April 4, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap for 
the enrollee has they did not receive adequate relief from traditional conservative methods and do not have 
instability to indicate fusion is the appropriate treatment. The Plan denied your request. The Plan says the 
requested service 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 considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested Intracept procedure is considered experimental. The reviewer 
found that additional research is needed to show safety and efficacy. Therefore, the reviewer found that the 
requested procedure is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endosteal implants (D6010x6). 
 
You asked the Plan to pre-approve the endosteal implants (D6010x6). You say that you require the implants 
because you do not have teeth and it is hard to eat and causing stomach issues. You say you cannot wait any 
longer. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
endosteal implants (D6010x6).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that this iron drug is the best option at this time. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our physician reviewer 
found that the enrollee has iron deficiency anemia. The requested medication is a new start. The Plan requires a 
trial of Infed and Venofer before they will approve the requested drug. The provided records do not indicate 
that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that 
the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
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 an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says an LTACH admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case the enrollee was admitted with respiratory failure in the setting of 
congestive heart failure. The record indicates that the enrollee has ongoing acute medical issues and but still 
require acute care services. The enrollee continues to receive acute care services and these have not been 
denied. The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injection (J0585). 
 
You asked the Plan to pre-approve a Botox injection. You say that the enrollee has a history of cervical 
myelopathy s/p ACDF C5-6 with RUE/RLE spasticity, right ICA stenosis; intermittent spams which are 
controlled with Baclofen; tone is increasingly getting worse. The Plan denied your request. The Plan says the 
requested service is not covered by Medicare or the health plan. 
 
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. Specifically, this injection is a benefit exclusion under your Medicare Advantage plan. The 
enrollee may have a separate commercial pharmacy benefit or Medicare Part D benefit managed by another 
carrier. Therefore, we decided that the Plan does not have to pre-approve Botox injection (J0585).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tymlos. 
 
You asked the Plan to pre-approve Tymlos. You say that you believe Tymlos is the most beneficial treatment 
option as well as medically necessary for the enrollee. The Plan denied your request. The Plan says this drug is 
not covered for the enrollee's condition by their Medicare Part B plan. 
 
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 Tymlos.  
 
Benefits for Tymlos 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve for 20 additional trips. 
 
You asked the Plan to pre-approve for 20 additional trips. You say that you are requesting 20 additional trips. 
The Plan denied your request. The Plan says the member is entitled to 40 one-way trips per year, which he has 
exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of a $0 copayment for up to 40 one-way trips to plan-approved locations 
every year trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve for 20 additional trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that glucose monitoring is an effective and 
important tool in managing diabetes. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for approval. 
 
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 the enrollee does not 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 and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies (K0553, K0554).
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 IRF care to regain maximum strength. The 
Plan denied your request. The Plan says your records do not show that you have complex rehabilitation needs 
that require frequent evaluation by a rehabilitation doctor or the care of a multi-disciplinary team in an 
intensive setting consisting of 3 hours of daily therapies. 
 
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 your 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 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 pre-approve the bone replacement graft for ridge preservation 
(D7953), the guided tissue regeneration (D4266), and the extraction (D7210). 
 
You asked the Plan to pre-approve the bone replacement graft for ridge preservation (D7953), the guided tissue 
regeneration (D4266), and the extraction (D7210). You say that you are appealing the denials. The Plan denied 
your request. The Plan says the services (D7953 and D4266) are not covered benefits and the requested 
provider is out-of-network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft for ridge 
preservation (D7953) and the guided tissue regeneration (D4266) are not among those covered under this 
benefit. The extraction (D7210) is not covered under this benefit when received from an out-of-network 
provider. Therefore, we decided that the Plan does not have to pre-approve the bone replacement graft for ridge 
preservation (D7953), the guided tissue regeneration (D4266), and the extraction (D7210).