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

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically reasonable and necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 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 indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical epidural steroid injection (62321). 
 
You asked the Plan to pre-approve a cervical epidural steroid injection. You say that this is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections should be performed 
in conjunction with conservative treatments and that patients should be part of an active rehabilitation program, 
home exercise program or functional restoration program. 
 
We looked at the file and Medicare rules. In this case, the documentation does not provide any evidence that 
the enrollee has performed conservative treatments and is actively involved in a rehabilitation program, home 
exercise program or functional restoration program. Based on this information, we decided that Medicare rules 
for coverage of a cervical epidural steroid injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cervical epidural steroid injection (62321).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the notes do not show progress with prior therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that based on the very limited available records, you appear to have 
improved with therapy to the point of being able to manage most of your activities of daily living with 
supervision or set-up assistance as of 12/23/2021. You were reported to be a resident of a skilled nursing 
facility. The records do not document goals for how much more independence you are expected to achieve 
given your nursing facility status. The records do not clarify that further utilization of a home exercise program 
is not appropriate for you. There is no documentation that the unique skills of a professional therapist are 
required to safely and effectively provide treatment. It does not appear that services can be safely and 
effectively performed only by a therapist or under the supervision of a therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic accessory and Power elevating leg rests. 
 
You asked the Plan to pre-approve the electronic accessory and Power elevating leg rests. You say that you 
would like reconsideration because these accessories are medically necessary. The Plan denied your request. 
The Plan says you do not meet Medicare criteria for coverage. 
 
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 electronic accessory and Power 
elevating leg rests. Our reviewer says that you have one power option of power tilt on the approved wheelchair. 
Your upper extremity strength and function support that you can control any power options through your own 
switches. Our physician reviewer found the documentation does not reveal that you have leg edema, 
contractures in the lower extremities, inability to flex your knees or require this to be used with the approved 
power tilt feature. The requested power leg rests exceed her medical need. 
 
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 electronic accessory and Power elevating leg rests have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the electronic accessory and Power elevating 
leg rests.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve the hearing aids. You say that the Plan's approved hearing aid brand is not 
very reliable and you would like to be approved for coverage for hearing aids that are not the Plan's approved 
brand. The Plan denied your request. The Plan says your plan only covers hearing aids when they are the Plan's 
approved hearing aid brand. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are the Plan's approved hearing aid brand. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-
approve hearing aids.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral formula. 
 
You asked the Plan to pre-approve the formula. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve enteral formula.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for hemodialysis. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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 hemodialysis.
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 you would like reconsideration because 
the LTACH admission is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be somewhat unstable and is still being treated for pneumonia 
with leukocytosis. The enrollee should only require short-term additional acute care services that can be safely 
completed at the current facility until more stable and appropriate for a lower level of care. There are no 
services at the LTACH that the patient requires that are not already available and covered at the current 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital services provided to the enrollee on June 
16, 2021. 
 
You asked the Plan to pay for the services. You say that the records show that this is medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules 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 99231 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem 
focused interval history; A problem focused examination; Medical decision making that is straightforward or of 
low complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the 
bedside and on the patient's hospital floor or unit." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation describes a post-operative follow-up for "right transfemoral implantaton of 23 mm Edwards SAPIEN 3 ultra transcatheter arctic 
valve on June 14, 2021."  In this case, this procedure would be inclusive to the global package, and not 
separately payable. 
 
We looked at this coder'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 pay for subsequent hospital services provided to the enrollee on June 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Positron Emission Tomography and Computed 
Tomography (PET CT). 
 
You asked the Plan to pre-approve PET CT. You say that you would like reconsideration because the requested 
PET CT is medically necessary. The Plan denied your request. The Plan says the requested study would exceed 
the allowed limit of three scans. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PET CT. Our reviewer says that the 
record indicates that the enrollee has stage IV metastatic breast cancer.  The record provided indicates that the 
enrollee has had six previous scans. Our physician reviewer found the elements of the coverage criteria 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 PET CT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Positron Emission Tomography and Computed Tomography (PET CT).
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 requires treatment in the 
LTACH for wound care. The Plan denied your request. The Plan says the LTACH admission does not meet the 
national guidelines. 
 
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 in this case the enrollee was admitted with Fourniers gangrene. The record indicates 
that the enrollee requires ongoing acute care services before transitioning to a lower level of care. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of Skilled Nursing Facility (SNF) care 
beyond March 5, 2022. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that you would like reconsideration 
because you need additional care and the previously approved days were not enough. The Plan denied your 
request. The Plan says your needs may be met at a lower level of 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 the continuation of SNF care. Our 
reviewer says that you do not require skilled nursing or skilled therapy services on a daily basis. Our physician 
reviewer found you do not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of Skilled Nursing Facility (SNF) care beyond March 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested shoe inserts are medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with 
neurogenic claudication. The record indicates that the enrollee has multi-level disease, including severe spinal 
stenosis at L4-L5, the level requested for treatment. In addition, the record does not state that the enrollee is not 
indicated for operative intervention at no more than two levels. The elements of the coverage criteria 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex device for the enrollee.
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. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the Medicare guidelines. 
 
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. You have a past 
medical history of Parkinson's disease and you are living at home with weakness despite home physical therapy. 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the enrollee is in severe eye pain. The Plan 
denied your request. The Plan says the requested services can be provided to the enrollee by 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 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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the services that can only be provided as an inpatient in a skilled nursing are not 
required. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no 
identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a 
daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in 
a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.