Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve Proton Beam Therapy (PBT) (77336, 77263, 77470, A9552). 
 
You asked the Plan to pre-approve PBT. You say that the requested therapy is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that studies have not shown any advantage of PBT 
compared to IMRT for enrollees with right breast cancer as it relates to the concerns noted for cardiac toxicity. 
The request for approval of proton radiation therapy is denied as not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 PBT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of proton therapy is an accepted radiation technology, that has proven efficacy and 
tolerability. Certain conditions such as base of skull chordomas and chondrosarcomas, and pediatric CNS 
malignancies are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose 
delivery to the tumor, while relatively sparing the neighboring normal tissue. As this enrollee had prior 
radiation to the same site, this would not be a routine case, and the need for proton therapy would be plausible. 
It is also notable that the enrollee was referred for proton therapy from another radiation oncology practice, 
suggestive that non-proton therapy was not considered feasible. Ideally, a well-designed comparison plan 
demonstrating the need for proton therapy would have been submitted and generating a composite plan would 
be a necessary standard of care for reirradiation. Only a proton plan was provided and there was not composite 
dosimetry which should be done to assure safe cord and brachial plexus exposures. Despite these issues, the 
reviewer believes that in the setting of reirradiation, particularly when treating a complex nodal target volume, 
proton therapy would be considered to furnished in accordance with accepted standards of medical practice. 
The decision is therefore favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have been met. Therefore, we decided that the Plan has to pre-approve 
Proton Beam Therapy (PBT) (77336, 77263, 77470, A9552).  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve cataract surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this request does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee's visual acuity with correction OD (right eye) 20/40 and OS (left eye) 20/50 with 3+ 
nuclear sclerosis in both eyes on slit-lamp exam. The ophthalmologist's clinical notes were not very descriptive 
in the patient's visual complaints to further support the diagnosis of visually significant cataracts warranting 
cataract surgery. However, multiple prior clinical notes from other providers on 1/18/2023 and 1/25/2023 with 
positive review of system that patient complains of "worsening blurry vision", "poor vision", and "wants to see 
an ophthalmologist".  In review of this entire appeal package that was submitted, agree that this meets 
medically necessary cataracts warranting cataract surgery to improve vision. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve cataract surgery.   
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: 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 feel that inpatient rehab is the most appropriate 
setting due to high level of care needs. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. 
 
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: Favorable

 
We decided that the Plan has to pre-approve sedation (D9239 and D9243). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied sedation 
because it is necessary with the dental procedures. The Plan denied your request. The Plan says that as per the 
evidence of coverage the criteria for sedation were not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide us with the evidence of coverage for the 
year of 2023. The Plan has not provided us with the information needed to make a determination regarding 
their denial and whether the criteria for the sedation has been met. Therefore, we decided that the Plan has to 
pre-approve sedation (D9239 and D9243).  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue 
(includes lipectomy); abdomen, infraumbilical panniculectomy. 
 You asked the Plan to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); 
abdomen, infraumbilical panniculectomy. 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 follows Medicare rules. Medicare rules say that abdominal lipectomy/panniculectomy is only covered 
for certain indications. 
 
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 excision, excessive skin and 
subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee underwent bariatric surgery in December 2021.  The record indicates that 
the enrollee continues to have weight loss. The record does not indicate the presence of chronic intertrigo that 
consistently remains refractory to appropriate medical therapy (e.g., topical antifungals, corticosteroids, 
antibiotics) over a period of three months. Therefore, the enrollee does not meet criteria for the requested 
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 excision, excessive skin and subcutaneous tissue (includes lipectomy); 
abdomen, infraumbilical panniculectomy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical 
panniculectomy.
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 really need to be in a rehabilitation facility 
because you have no one at home that can provide the care you need. 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 physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as 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: 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. The Plan denied your request. The Plan says based upon your 
current level of function you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirement. 
 
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 Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary in this case. Our physician reviewer found that the record 
indicates that the enrollee has osteoarthritis of the knee. The requested medication is a new start. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity test and extremity study. 
 
You asked the Plan to pre-approve a lower extremity test and extremity study. You say that a lower extremity 
test and extremity study is medically necessary. The Plan denied your request. The Plan says the requested 
lower extremity test and extremity study does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 lower extremity test and extremity study. Our reviewer says that a lower extremity test and extremity study is not medically necessary in this case. 
Our physician reviewer found that the documentation does not support the medical necessity of the studies in 
question. The description of the enrollees symptoms is inadequate on which to justify the study in question. 
Additionally, there is no documentation of arterial pulses or any other assessment of lower extremity arterial 
perfusion. There is no documentation of an assessment or plan suggesting the desire to order a lower extremity 
arterial study.  
 
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 lower extremity test and extremity study have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lower extremity test and extremity study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0245). 
 
You asked the Plan to pre-approve a shower chair. You say that the item should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0245).
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 member can remain in the current 
acute care location until such time no further acute level care is needed. The Plan denied your request. The Plan 
says an LTACH admission is 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 the record indicates that the enrollee has ongoing acute medical issues and still 
requires 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. 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has chronic obstructive 
pulmonary disease (COPD related to her chronic obstructive airway disease and encephalophacy. The enrollee 
needs this device when she goes home and if she does not get it, she will decline and pass away. This machine 
helps to release the CO2 as the enrollee no longer has the ability to do so. The Plan denied your request. The 
Plan says the request for a home mechanical ventilator set in PS with Safety Tidal Volume mode that could be 
delivered by BiPAP is not covered. 
 
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 service is not medically necessary. Our physician reviewer found the enrollee has severe COPD with a 
recent exacerbation requiring hospitalization. ABG was consistent with acute on chronic hypercarbic 
respiratory failure. There is no ABG done while stable to document chronic CO2 retention. If there is chronic 
CO2 retention, the enrollee may benefit from BiPAP with AVAPS during sleep. This has not been tried and 
shown to fail as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
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 (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implanted loop recorder (ILR). 
 
You asked the Plan to pre-approve ILR. 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. 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 ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had a recent noninvasive heart monitoring for two weeks revealing a 
predominantly sinus rhythm, minimum heart rate of 54 and maximum heart rate of 214. Three weeks of 
noninvasive Holter monitoring should be completed before making a decision about an ILR. Therefore, the 
enrollee does not meet criteria for the requested 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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve implanted loop recorder (ILR).