Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from LTACH 
admission to regain maximum/prior level of functioning and continue multidisciplinary approach to care. The 
Plan denied your request. The Plan says the enrollee's records do not show that your doctors expect you will 
benefit and improve with LTACH care, and hospice or comfort care is more appropriate according to the most 
recent records provided. 
 
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 is receiving appropriate care at the present acute care hospital and does 
not require services at the LTACH that are not available at the current acute care hospital. 
 
 
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy. 
 
You asked the Plan to pre-approve home health services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found there is no 
documentation that further skilled therapy services meet criteria for coverage. The enrollee has met all short-
term goals and 80% of long-terms goals and is compliant with a home exercise program. Further utilization of 
the home exercise program appears appropriate at this point. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified restorative procedure (D2999), a hybrid 
upper denture (D6114), a hybrid lower denture (D6115), precision attachments (D6950), and an office visit 
(D9430) for tooth #20 and #29 provided on March 7, 2022, March 14, 2022, April 14, 2022, and May 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures were medically necessary 
and there were no providers in your area. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because the unspecified restorative procedure, the hybrid dentures, precision 
attachments, and the office visit are not covered by the Plan. 
 
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 pay for the 
unspecified restorative procedure (D2999), a hybrid upper denture (D6114), a hybrid lower denture (D6115), 
precision attachments (D6950), and an office visit (D9430) for tooth #20 and #29 provided on March 7, 2022, 
March 14, 2022, April 14, 2022, and May 19, 2022.
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 requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/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 proton beam therapy. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is insufficient prospective, long-term, clinical data available to determine whether 
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. 
 
 
  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: 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 requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the IRF services requested 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 complexity of your nursing, rehab, and medical needs do not require an acute 
hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. While you may benefit 
from physical and occupational therapy, your rehabilitation needs can be provided in a lower intensity and 
alternate setting such as in a 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 09, 2022. 
 
You asked the Plan to pay for an office visit. You say that the enrollee has out-of-network benefits. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 09, 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 enrollee will not survive if moved to 
an improper facility without life-saving equipment. The Plan denied your request. The Plan says the requested 
LTACH admission is 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the Plan. 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting IRF services so you can regain 
your strength and walk. You also say you need to gain maximal function so you can get home and take care of 
yourself. The Plan denied your request. The Plan says the requested IRF services are 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 the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an 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 enrollee is medically ready for transfer to 
inpatient rehabilitation and further delay will continue to affect strength, medical stability, and ability to 
discharge safely home. The Plan denied your request. The Plan says the enrollee does not need an intensive 
team of rehabilitation doctor and nurse, social worker, and therapists for your care, medically necessary care 
may be provided safely in a different 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 the enrollee does not require the intensity of services provided at 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 treatment with Xipere (J3299). 
 
You asked the Plan to pre-approve Xipere. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an off-label, 
not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Xipere. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of cystoid macular edema following cataract surgery. The FDA has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain 
a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xipere have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Xipere (J3299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on June 1, 2022, by an out-
of-network (OON) provider. 
 You asked the Plan to pay for the wound care supplies. You say that wound care supplies are a separately 
billable expense that do not require prior authorization. The Plan denied your request. The Plan says the wound 
care supplies are not separately reimbursable. 
 
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 the wound care supplies provided on June 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on December 21, 2022.  
 
You asked the Plan to pay for the limited oral evaluation - problem focused. You say that you suffered damage 
to a tooth that required dental care both comprehensive and preventative. You also say that this type of visit of 
this nature would be covered generally by insurance. The Plan denied your request. The Plan says this service 
is not covered under the benefit package. 
 
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 pay for a limited oral evaluation - problem focused 
(D0140) provided on December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb stimulator (Cala Trio device) 
(K1018), and supplies (K1019). 
 
You asked the Plan to pre-approve Cala Trio device. You say that approval for essential tremor was supported 
by data from a clinical trial. The Plan denied your request. The Plan says the requested device 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 Cala Trio device. Our reviewer says 
that the requested Cala Trio device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation are insufficient to establish the medical necessity of the 
requested service. The reviewer also found there is insufficient literature to support the safety and efficacy of 
the requested service for the enrollee's condition. Therefore, the reviewer found that the requested Cala Trio 
device is not medically reasonable or 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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an external upper limb stimulator (Cala Trio device) (K1018), and supplies (K1019).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that the enrollee would benefit from a thorough sleep 
evaluation. The Plan denied your request. The Plan says this test is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat polysomnography or sleep testing for 
diagnosing sleep apnea requires documentation justifying the medical necessity for the repeated test. 
 
 
  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 sleep study. Our reviewer says that a 
diagnostic polysomnogram is not medically necessary. Our physician reviewer found this enrollee has a 
diagnosis of obstructive sleep apnea, and is indicated as being intolerant of continuous positive airway pressure 
(CPAP). The enrollee is being referred for possible implantation of a hypoglossal nerve stimulator. However, 
the enrollee's Body Mass Index (BMI) is 35.1, and Medicare criteria include BMI less than 35, so the enrollee 
does not currently meet criteria for the hypoglossal nerve stimulator. Our reviewer found that there are no 
details of previous CPAP treatment and efforts to achieve tolerance, and there is no indication of whether the 
enrollee would be willing to try CPAP again. Our physician reviewer also found that since the enrollee does not 
meet criteria for the hypoglossal nerve stimulator, and that is the reason for the repeat sleep study, the denial is 
upheld. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis 
vaccine (Tdap) (90715) provided on November 10, 2022. 
 
You asked the Plan to pay for the Tdap vaccine. The Plan denied your request. The Plan says the TDAP 
vaccine is a Part D drug in which is not a covered benefit under this medical plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. 
Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715) provided on November 10, 2022.  
 
  Benefits for the Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.