Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request is not medically necessary for the enrollee's condition. 
 
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 requested services. Our physician 
reviewer found that in general radiation is used in the setting of bladder preservation after gross disease has 
been surgically removed. Clinically meaningful reduction in the bowel volume receiving greater than 40-45 
gray (Gy) can warrant consideration of IMRT as can limiting hot spots in the bowel in excess of 50-60 Gy. 
However, the prescribed dose in this enrollee is apparently only 50 Gy in 25 fractions, albeit with concurrent 
chemotherapy. The medical records do not offer an explanation as to why, or offer a quantifiable rationale, for 
why IMRT is needed in this case. No specific information about a three dimensional (3D) conformal plan being 
unacceptable was provided. Without justification for the need of IMRT (over standard 3D conformal 
radiotherapy), the request is not medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this device for the purpose of prevention of venous 
thromboembolism is a preventive service. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you will never get better and be able to go home if 
you can't get out of the current facility and into a facility that will take care of you and treat you. The Plan 
denied your request. The Plan says criteria for admission to a SNF have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
your condition. Your care needs can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they do not meet the 
clinical requirements to be approved. 
 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 that 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 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: 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 require close medical oversight regarding your 
complex medical issues. You say you are highly motivated and are pushing yourself every single session so 
you can return home. The Plan denied your request. The Plan says based on Medicare guidelines, 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 that your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. 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 acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine/Naloxone. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
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 Buprenorphine/Naloxone.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection (20610), and needle localization (77002) 
provided on February 4, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were 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 pay for the outpatient services. Our reviewer says 
that the requested outpatient services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate a recent trial and failure of adequate 
conservative measures, including physical therapy and a knee steroid injection. Therefore, the reviewer found 
that the services in this case were not medically 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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the injection (20610), and needle localization (77002) provided on February 4, 2022.
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 the LTACH stay is medically necessary. 
The Plan denied your request. The Plan says the LTACH stay is denied as 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 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 LTACH services.
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 IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 available clinical documentation does not show any complex functional 
impairments (or IRF-compliant diagnosis) or active medical issues (anemia stable, stable on antibiotic regimen, 
electrolytes stable). The complexity of the enrollee's nursing, medical and rehabilitation needs would not be expected to 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transmitter; external, for use with interstitial 
continuous glucose monitoring system (A9277). 
 
You asked the Plan to pre-approve a transmitter. You say that services should be covered because the 
transmitter went out of warranty on November 15, 2022, and needs to be replaced. The transmitter cannot be 
replaced, repaired, or refurnished. The Plan denied your request. The Plan says the requested external 
transmitter for use with an interstitial CGM is specifically excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a A9277 describes the supplies used with a CGM 
that does not meet the definition of DME. 
 
We looked at the file and Medicare rules. The requested transmitter is specifically excluded from coverage. 
Based on this information, we decided that Medicare rules for coverage of a transmitter have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a transmitter; external, for use with interstitial 
continuous glucose monitoring system (A9277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Guardian Sensor 3. 
 
You asked the Plan to pre-approve a Guardian Sensor 3. You say that the sensors help keep your blood sugar 
under control. You have been a diabetic for 40 years and you were receiving these sensors directly from the 
manufacturer. Now you are trying to get these sensors from the Plan's preferred provider. The Plan denied your 
request. The Plan says to approve a medical exception, the Plan needs to know whether you have had an 
inadequate response with both a Dexcom CGM system and a Freestyle Libre CGM system, or clinical rationale 
for why each product cannot be used. This was not received; therefore, you do not meet approval for the 
requested sensor. 
 The Plan must follow Medicare rules. Medicare rules say that the Plan generally will not cover other brands of 
monitor and test strips unless you or your provider request a medical exception. 
 
We looked at the file and Medicare rules. The records show that a medical exception was not submitted, 
therefore, the requested sensor is not a covered benefit with your Plan. Based on this information, we decided 
that Medicare rules for coverage of a Guardian Sensor 3 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Guardian Sensor 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of benign odontogenic cyst or tumor - lesion 
diameter up to 1.25 cm (D7450). 
 
You asked the Plan to pre-approve removal of benign odontogenic cyst or tumor. You say that the service is 
necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
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 
removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm (D7450).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 8, 2022, to 
April 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes, 
HHAs must report an additional line item with the same revenue code and date of service, reporting one of the 
three Q codes (Q5001, Q5002, and Q5009), one unit and a nominal covered charge.  
 
We looked at the file and Medicare rules. The file shows that the services were not billed with one of the 
required Q codes matching the dates of service at issue. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the home health services rendered from February 8, 2022, to April 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need additional time to be approved for a longer 
stay at the SNF. The Plan denied your request. The Plan says you do not meet the medical necessity criteria for 
a continued SNF stay. 
 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. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. You are 
at or near your prior level of function and you could be discharged to a lower level of care for further 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology testing (81479), molecular 
pathology procedure level 6 (81405), and molecular pathology procedure level 7 (81406) provided on August 
25, 2022. 
 
You asked the Plan to pay for the molecular pathology procedures. You say that the lab services should be 
covered. The Plan denied your request. The Plan says the molecular pathology procedures do not meet the 
definition of medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the molecular pathology procedures. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the provided medical records do not document how the results of the 
testing would change management of the enrollee and records do not show that use of the unlisted molecular 
pathology testing (81479), molecular pathology procedure level 6 (81405), and molecular pathology procedure 
level 7 (81406) has been shown in controlled studies to result in long term health benefits in patients with dementia. Also review of the current per-reviewed medical literature (including Up to Date) does not support 
the utility of the molecular pathology testing in the work-up or evaluation or treatment of dementia. 
 
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 molecular pathology procedures have not been met. Therefore, we decided 
that the Plan does not have to pay for the unlisted molecular pathology testing (81479), molecular pathology 
procedure level 6 (81405), and molecular pathology procedure level 7 (81406) provided on August 25, 2022.
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 are motivated and willing to participate in 
therapy three hours per day, five days per week to maximize your potential while medically stabilizing. The 
Plan denied your request. The Plan says you do not meet the criteria for admission to an IRF. 
 
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 your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. 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 acute IRF admission and services.