Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services provided on August 31, 2021. 
 You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says an authorization 
was not obtained prior to the services being rendered and the provider is not participating with the member's 
Plan. 
 
We looked at the file and the Plan's rules. The file shows that the vision services must be provided by a 
participating provider. Based on this information, we decided that the Plan's rules for coverage of the vision 
services have not been met. Therefore, we decided that the Plan does not have to pay for vision services 
provided on August 31, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 16, 2020 to February 19, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim has not been billed correctly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered.  
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was billed with a date of service range from January 16, 2020, through February 19, 2020. This is a 35 day 
episode of care and is does not meet Medicare guidelines for billing home health services. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from January 
16, 2020 to February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FreeStyle Libre Continuous Glucose Monitor (CGM) and 
supplies (K0553) provided on May 22, 2021. 
 
You asked the Plan to pay for the FreeStyle Libre CGM. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
include a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the documentation submitted does not support that 
the member's treating physician ordered these supplies. Additionally, the medical records submitted do not 
support that the enrollee's physician discussed the need for these supplies. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the FreeStyle Libre Continuous Glucose Monitor (CGM) and supplies (K0553) 
provided on May 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on August 30, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test would establish specific mutations. The 
Plan denied your request. The Plan says the testing has not been shown to improve outcomes or significantly 
change management. 
 
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 testing services. Our physician reviewer 
found that the enrollee was being treated for resected cholangiocarcinoma. She was to received adjuvant 
treatment. molecular testing would be reserved for recurrent or metastatic disease. Therefore, the testing was 
not medically reasonable or necessary for the enrollee in this case. 
 
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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the gene panel testing provided on August 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing (home health) services. 
 
You asked the Plan to pre-approve private duty nursing. You say that you are completely dependent on 
someone to take care of her and you have a lot of medical conditions that need to be addressed. The Plan 
denied your request. The Plan says these services are not medically necessary because you no longer require 
skilled therapy as of April 13, 2022. 
 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 private duty nursing. Our reviewer says 
that private duty nursing home health services are not medically necessary. Our physician reviewer found there 
is no evidence that you currently have skilled nursing needs or skilled therapy needs.  As such, there is no 
evidence that home health services are medically necessary and reasonable to assist in the skilled treatment of 
acute illness or injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of private duty nursing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve private duty nursing (home health) 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower 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. 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 was admitted for weakness and 
metabolic encephalopathy. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 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 this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex device placement surgery for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that review of the current medical literature indicates that this service 
is considered experimental and investigational. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex device placement surgery for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invokana for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
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 Invokana for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar transforaminal epidural injections. 
 
You asked the Plan to pre-approve lumbar transforaminal epidural injections. You say that the enrollee is in 
severe pain and is unable to perform activities of daily living. The Plan denied your request. The Plan says the 
clinical information provided does not describe pain that radiates along the dermatome of a nerve, and therefore 
the requested procedure is not indicated at this time. 
 
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 lumbar transforaminal epidural 
injections.  Our reviewer says that the lumbar transforaminal epidural injections are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the records show the request is for 3 epidurals in one 
session. Medicare rules do not allow for coverage of multiple blocks during the same session as ESIs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar transforaminal epidural injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lumbar transforaminal epidural injections.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services. 
 
You asked the Plan to pre-approve home health care services. You say that the records provided support the 
need for home healthcare services. The Plan denied your request. The Plan says the clinical scenario does not 
call for home health skilled nursing services. 
 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 care services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee does 
not have documented skilled nursing needs. The enrollee has available caregivers. The requested ongoing home 
health skilled nursing services are not medically necessary or reasonable. 
 
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 care services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health care services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from August 10, 2021, to 
August 11, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says the inpatient admission was not medically necessary. 
 
 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care provided from August 10, 2021, to August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. 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 on review of the available records, you had a transient ischemic attack / stroke. 
You are medically stable, with no new medical issues, and do not need physical medicine and rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. With a mild stroke/ transient ischemic attack, 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 to daily therapy in an IRF. While you may benefit from physical and occupational 
therapy, your rehab can be safely provided at a lower intensity and alternate setting such as in a skilled nursing 
facility. IRF admission is not medically necessary based on medical stability and lack of medical complexity, 
and lack of rehab nursing needs. Document does not support the necessity for admission to an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Victoza. 
 
You asked the Plan to pre-approve Victoza. You say that this drug is medically reasonable for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
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 Victoza.  
 
 
 Benefits for Victoza may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) services. 
 
You asked the Plan to pre-approve the CT scan. You say that the clinical documentation supports the need for 
the requested CT scan. The Plan denied your request. The Plan says a CT scan is not indicated for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has hormone refractory 
prostate cancer with PSA response and a CT of the abdomen/pelvis showing response. The enrollee had a CT 
of the chest in the past which shows a stable 7mm nodule. The requested CT scan 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
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 
service is medically necessary. Our physician reviewer found you needed multiple attempts to complete 
transfers. The documentation supports that your therapy goals have not been met, and that it is medically 
reasonable and necessary to provide skilled therapy services on a daily basis on 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the records provided support the need for the 
drug in dispute. The Plan denied your request. The Plan says the drug being requested is covered under the 
pharmacy benefit and the enrollee's contract does not include a pharmacy or drug plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.  
 Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Purewick urinary collection system with suction 
pump coded as K1006 and A9999 for related supplies. 
 
You asked the Plan to pre-approve the Purewick system. You say that this is the best option for you in order to 
keep moisture away and prevent skin issues. The Plan denied your request. The Plan says this is not a covered 
item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable. The rules do allow for certain urological supplies when 
they fall into the Prosthetics Benefit category.  
 
In this case, the suction pump which is a component of the Purewick system is not used to replace a malformed 
body part. It is also not listed among the covered codes for urological supplies covered under this benefit. 
Without a covered benefit category, we find that this system does not meet Medicare coverage criteria.  
  Therefore, we decided that the Plan does not have to pre-approve the Purewick urinary collection system with 
suction pump coded as K1006 and A9999 for related supplies.