Persius/hicric huggingface dataset:
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 the enrollee would greatly benefit from therapy 
services at a skilled nursing facility. The Plan denied your request. The Plan says the criteria for medical 
necessity has 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 the enrollee was at a minimal assist level for bed mobility but required moderate to 
maximal assist for transfers and required varying assist with activities of daily living skills. The enrollee does 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our reviewer also found the enrollee does 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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
neck. 
 
You asked the Plan to pre-approve CTA of the neck. You say that you need this imaging to find out why you 
are losing your ability to move. 
 The Plan denied your request. The Plan says CTA of the neck is not medically necessary and reasonable. 
 
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 CTA of the neck. Our reviewer says 
that CTA of the neck is not medically necessary. Our physician reviewer found you are a 49-year-old female 
with a history of Arnold Chiari malformation who presented with anterior cervical and supraclavicular 
adenopathy and fibrous cysts on the chest and painful cysts on your extremities. Your provider 
recommended CTA. CTA identifies abnormalities, such as aneurysms, in the aorta, both in the chest and 
abdomen, or in other arteries. detect atherosclerotic (plaque) disease in the carotid artery of the neck, which 
may limit blood flow to the brain and cause a stroke, and identify a arteriovenous malformation inside the brain 
or elsewhere. The appropriate study is CT scan of the soft tissue of the neck with contrast, but this was not 
requested. There is no indication for the requested CTA of the neck. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CTA of the neck have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomographic angiography (CTA) of the neck.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coronary computed tomographic angiography (CTA). 
 
You asked the Plan to pre-approve a cardiac CTA. You say that the patient has all of the risk factors for heart 
disease, so this test is medically necessary. The Plan denied your request. The Plan says CTA is not medically 
necessary. The patient has had episodes of chest pain and other cardiac symptoms. She has had a complete 
cardiac work up and the results were negative. 
 
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 a cardiac CTA. Our reviewer says that 
cardiac CTA is not medically necessary. Our physician reviewer found Cardiac workup, including stress 
testing, has been negative. Clinical guidelines for the use of coronary CTA have not been met based on review 
of the submitted clinical documentation. As a result, at this time coronary CTA would not be considered 
medically reasonable and necessary in this patient's clinical management. 
 
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 cardiac CTA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve coronary computed tomographic angiography (CTA).
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 that the coverage 
criteria has 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 enrollee is functioning at a high level and does not require intensive 
rehabilitation or frequent physiatry oversight. 
 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 pay for an otolaryngology visit provided on June 8, 2022, to June 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an otolaryngology visit. You say that you are trying to get this preauthorization 
done with your PCP office. The Plan denied your request. The Plan says there was no preauthorization by a 
primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and 
this was not an emergency. The plan contacted your provider's office, and they still have not provided this 
authorization. Therefore, the decision is upheld. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an otolaryngology visit provided on June 8, 2022, 
to June 22, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you need continued therapy in order to be 
as mobile as you were prior to your hospitalization.  The Plan denied your request. The Plan says the clinical information has been reviewed and the requested 
continued SNF services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found you received physical therapy and are at minimal to maximal/total 
assist level with functional mobility. You do not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also 
found you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued 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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
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. The enrollee 
was admitted for pneumonia and tracheitis. Medical problems are stable.  There are no complex or nursing rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office consultations and treatment to be provided by an 
out-of-network (OON) urology provider. 
 
You asked the Plan to pre-approve the OON urology services. You say that OON care is medically necessary 
as the in-network providers do not deal with the enrollee's issues at their clinic. The Plan denied your request. 
The Plan says in-network care is 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 provider at issue in this case is not a network provider with the Plan. 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 OON urology services. Our reviewer says that out-of-network urology 
treatment is not medically necessary. Our physician reviewer found the plan's denial is medically justified on 
the basis that it is offering adequate care to meet the enrollee's medical needs through referral to network 
urology providers in Seattle and Tacoma. There is nothing unique about the enrollee's condition that would make it medically necessary for her to see the requested out-of-network provider. The plan has shown that they 
have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the OON urology services have not been met.  
 
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 the OON urology services. Therefore, we decided that 
the Plan does not have to pre-approve office consultations and treatment to be provided by an out-of-network 
(OON) urology provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minimally invasive lumbar decompression (MILD) 
(0275T) procedure. 
 
You asked the Plan to pre-approve the MILD procedure. You say that the requested MILD procedure is 
medically necessary The Plan denied your request. The Plan says the enrollee is not participating in an 
approved clinical study for evidence development. 
 
The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar 
Decompression (PILD) will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the minimally invasive lumbar decompression have not been met. Specifically, the enrollee is not 
enrolled in a clinical study. Therefore, we decided that the Plan does not have to pre-approve the minimally 
invasive lumbar decompression (MILD) (0275T) procedure.
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 physician oversight and therapy services in 
an IRF to ensure that you are not readmitted to the hospital. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 in this case, the complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that he would 
meet criteria for admission to an acute inpatient rehabilitation facility.  There is no indication that you would 
require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain your functional status. You can receive further 
services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the enrollee needs this treatment. The 
Plan denied your request. The Plan says proton beam therapy is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient prospective, long-term clinical data available to determine 
whether or not proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external 
beam radiation therapy, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety 
and efficacy. Recent data shows no significant differences in late (years one, two, and three) patient-reported 
toxicity outcomes between proton beam therapy and IMRT.  The most recent American Urological Association 
and National Comprehensive Cancer Network (NCCN) guidelines state that proton beam therapy offers no 
clinical advantage over other forms of definitive treatment. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to provide a positron emission tomography (PET) scan. 
 
You asked the Plan to provide a positron emission tomography (PET) scan. You say that you would like to use 
an OON provider. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
The Plan must follow Medicare rules. Medicare rules say that a PET scan must be received in-network. 
Therefore, we decided that the Plan does not have to provide a positron emission tomography (PET) scan. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a positron emission tomography (PET) scan have not been met. Therefore, we decided that the 
Plan does not have to provide a positron emission tomography (PET) scan.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT), head or brain (70450) provided 
on November 10, 2021. 
 
You asked the Plan to pay for the CT. You say that this should be covered. The Plan denied your request. The 
Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of 
Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The 
Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and 
to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for computed tomography (CT), head or brain (70450) provided 
on November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the ventilator is to be used for treatment of COPD 
and chronic narcotic use. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in AVAPS mode with Auto-EPAP (AE) 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 ventilator. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of COPD and is 
also on chronic narcotics for pain. The enrollee was recently hospitalized with pneumonia and ABG was 
consistent with chronic hypercarbic respiratory failure, with PaCO2 of 80.  The enrollee has refused CPAP or 
BiPAP. If the enrollee were to accept it, may benefit from BiPAP with AVAPS during sleep. Medicare does 
not cover a home ventilator when used as 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe chronic 
obstructive pulmonary disease (COPD) and an arterial blood gas (ABG) study done during recent 
hospitalization was consistent with chronic hypercarbic respiratory failure. The enrollee may benefit from bi-
level positive airway pressure (BiPAP); however, Medicare does not cover a home ventilator when used as 
BiPAP. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.