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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has a flap closure performed 
on February 2, 2023, and needs to be in the hospital for at least for weeks for flap site to be healed enough. You 
also say that the enrollee is fairly unreliable when they are out of the hospital, and does not follow instructions 
very well if they do not have regular guidance. The Plan denied your request. The Plan says the LTACH 
services requested 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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. Our reviewer found that 
the enrollee does not require services at the LTACH that are not available at the acute care hospital where they 
are currently receiving care. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. Our physician reviewer also found that 
the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bioimpedance spectroscopy (BIS) using the ImpediMed 
L-Dex testing device. 
 
You asked the Plan to pre-approve Bioimpedance spectroscopy (BIS) using the ImpediMed L-Dex testing 
device. You say that the requested Bioimpedance spectroscopy (BIS) using the ImpediMed L-Dex testing 
device is medically necessary. The Plan denied your request. The Plan says the requested Bioimpedance 
spectroscopy (BIS) using the ImpediMed L-Dex testing device 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 Bioimpedance spectroscopy (BIS) 
using the ImpediMed L-Dex testing device. Our reviewer says that the requested Bioimpedance spectroscopy 
(BIS) using the ImpediMed L-Dex testing device is not medically necessary. Our physician reviewer found the 
enrollee has a diagnosis of Malignant neoplasm of upper-outer quadrant of right female breast, treated with 
lumpectomy, sentinel node biopsy, and radiation. The enrollee has a diagnosis of lymphedema, treated with 
compressive garments, manual lymphatic drainage, and self-care management with K-Tape with reduction in swelling.  
 
The National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2022 Survivorship states 
lymphedema does not recommend BIS in the management of lymphedema. The evidence in the medical 
literature and the clinical documentation in this case are insufficient to support that bioimpedance spectroscopy 
is medically reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bioimpedance spectroscopy (BIS) using the ImpediMed L-Dex testing device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Bioimpedance 
spectroscopy (BIS) using the ImpediMed L-Dex testing device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 2 kit. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 shows that you do not require multiple daily 
doses of insulin, you do not require treatment with a continuous subcutaneous insulin infusion pump, you do 
not require frequent daily adjustments of insulin based on blood glucose testing. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the FreeStyle Libre 2 kit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint PNS system (64555). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says Medicare says this treatment cannot be approved for this type of pain. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Sprint PNS system is experimental for pain treatment. More research is needed.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint PNS system (64555).
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided safely at a 
lower level of care such as at a Skilled Nursing Facility, on an intermittent basis at home with home health 
care, or in a long-term care setting. 
 
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 patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not require intensive physician and nursing oversight in an IRF. While the patient may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the patient requires this therapy on an intensive IRF level. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-network coverage for out-of-network treatment while 
you are in Florida. 
 
You asked the Plan to pre-approve in-network coverage for out-of-network treatment while you are in Florida. 
You say that the office visits and infusions are life-saving treatment for a cancer without a cure and you cannot 
go the entire time in Florida without continuing treatment. The Plan denied your request. The Plan says the 
requested provider is out of the Plan's service area and not part of the network. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved 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 in-network coverage for out-of-network 
treatment while you are in Florida. Our reviewer says that the enrollee does not meet criteria for approval of 
out of area services as the services are not for an unforeseen illness or condition. Our physician reviewer found Medicare says that urgently needed services are those needed because of an unforeseen illness or condition, and 
it is not reasonable to get the services from the plan. The enrollee does not meet criteria for approval of out of 
area services as the services are not for an unforeseen illness or 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 in-network coverage for out-of-network treatment while you are in Florida have 
not been met. Therefore, we decided that the Plan does not have to pre-approve in-network coverage for out-of-
network treatment while you are in Florida.
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 you had a fall and broke your leg and feet. The Plan 
denied your request. The Plan says it appears you no longer require daily skilled therapy to be delivered by a 
licensed therapist. The Plan also says you do not require daily skilled nursing to be delivered by a Registered 
Nurse (RN) or Licensed Practical Nurse (LPN) as skilled services can now be safely delivered on an 
intermittent basis.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also 
found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper and lower dentures. 
 
You asked the Plan to pre-approve the requested dentures. You say that your dentist has tried to fix your 
current dentures 12 times already, and they are still not usable. You feel that another set should be covered. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 25, 2020. Therefore, 
we decided that the Plan does not have to pre-approve complete upper and lower dentures.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF care. 
 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 continued SNF care. Our reviewer says 
that the enrollee does not meet criteria for continued SNF care. Our physician reviewer found you do not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says that the 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
provided records do not document any acute or unstable medical conditions, any new injuries or changes in 
medication or treatment which would necessitate any further skilled therapy visits beyond what have already 
been approved. The records document the enrollee is unable to cooperate with therapy or follow instructions. 
Medical notes from the enrollee's treating physician do not support the need for skilled nursing or 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar decompression L2-L3 (22513 and 99152) 
 
You asked the Plan to pre-approve the services. You say that the enrollee is not enrolled in a Medicare 
approved study. You state that is something that has never been required in the past and you are not sure what 
this means. The Plan denied your request. The Plan says lumbar decompression L2-L3 is denied as Centers for 
Medicare & Medicaid Services (CMS) Medicare only covers this procedure when it is part of a Clinical Trial. 
The Plan states other procedures are covered by Medicare to address the stenosis and symptoms. The Plan 
states there is no documentation that this procedure was done as part of a Medicare approved clinical trial, and 
as such is denied. 
 
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 interspinous process devices are experimental in spine surgery. More research is needed to show safety 
and efficacy. 
 
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 the lumbar decompression L2-L3 (22513 and 99152)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met at an alternate 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. Our 
physician reviewer found that 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. While you can benefit from physical 
and occupational therapy, your needs can be safely provided in an alternate level of care such as a skilled 
nursing facility. 
 
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 IRF admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Carboplatin (J9271). 
 
You asked the Plan to pre-approve Carboplatin. You say that the medical records show the medical necessity of 
this request. The Plan denied your request. The Plan says that the use of this drug/regimen is not reasonable and 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Carboplatin. Our reviewer says that 
Carboplatin is medically reasonable and necessary for the enrollee. Our physician reviewer found the use of 
Carboplatin is supported by the National Comprehensive Cancer Network (NCCN) Guidelines, Version 
1.2023, for Head and Neck Cancers. Our reviewer also found that the documentation supports that the 
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Carboplatin have been met. Therefore, we decided that the Plan has to pre-
approve Carboplatin (J9271).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's upper extremity function is adequate to control the power options using 
their own switch which are included in the allowance of these power options. 
 
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 that the enrollee had adequate strength to manage the standard power switches. The enrollee has 4+/5 
strength in the upper extremities.  
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 electronic connection (E2311).