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

 
We decided that the Plan does not have to pre-approve an office visit (99204) with an oncologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the enrollee wants to see an oncologist right 
away as her cancer cells are spreading. The Plan denied your request. The Plan says the service requested can 
be rendered by equally qualified in-network providers. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99204) with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has very severe COPD 
subsequent to chronic respiratory failure that makes it very difficult for him to breathe on his own at night. You 
also say it is stated that BiPAP ST, ASV, and BiPAP AVAPS are all ruled out due to the severity of the 
enrollee's respiratory impairment. The Plan denied your request. The Plan says records do not show that the 
enrollee failed BiPAP therapy while hospitalized. The enrollee was treated with BiPAP, and records indicate 
his breathing improved and the BiPAP was weaned. Additionally, it is not clear if you had elevated PaCO2 
levels once you medically stabilized. Also, the noninvasive ventilator ordered is meant to be used exclusively 
in a setting that is available on BiPAP devices. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic hypoxic and hypercapnic respiratory failure from chronic obstructive pulmonary disease. The 
record indicates that the enrollee was treated in the hospital with BiPAP. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated 
coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. 
The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoulder arthroplasty procedure. 
 
You asked the Plan to pre-approve the requested services. You say that you have no use of your right arm. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that you have deltoid weakness. This is a contraindication to shoulder replacement surgery. 
Therefore, the requested service 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 a shoulder arthroplasty procedure.
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 that the enrollee has chronic respiratory failure from chronic obstructive 
pulmonary disease (COPD). The records do not contain sufficient detailed information to justify use of a home 
ventilator. The criteria for coverage are not met and the home ventilator is not reasonable or medically 
necessary at this time. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right total hip arthroplasty. 
 
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. 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 services are not medically necessary. Our physician reviewer found that the enrollee is being treated for 
right hip osteoarthritis. There is no detailed documentation of a trial and failure of recent, reasonable, and 
comprehensive less-invasive conservative care measures, including formal physical therapy. There is also no 
documentation of significant deficits that limit her overall quality of life and activities of daily living. The 
records do not support that the total hip arthroplasty is 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 right total hip arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiation therapy (77290, 0394T, 77280). 
 
You asked the Plan to pre-approve the radiation therapy. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the form of radiation therapy that delivers a high dose of radiation 
inside, or very close to the cancer tissues (high dose rate electronic brachytherapy, with associated therapeutic 
radiology simulation-aided field testing) requested does not meet the requirements for approval. The Plan states 
the enrollee's records do not show that the enrollee has undergone clinic staging, consideration for resection of 
the remaining lesion, or consideration for alternate radiation treatment options. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested for coverage type of radiation therapy in this case is not a standard of 
care, because it is considered investigational for the treatment of cancer diagnosed in this enrollee. 
 
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 radiation therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the radiation therapy (77290, 0394T, 77280).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. 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 the enrollee 
does not have documented, ongoing, skilled physical therapy needs and the enrollee is functioning at a level 
commiserate with 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom shoe supports to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve custom shoe supports. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan and the needed equipment can 
be obtained within the Plan network. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
custom shoe supports to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alymsys (Q5126) in combination with FOLFOX 
(leucovorin (J0640), fluorouracil (J9190), and oxaliplatin (J9263)). 
 You asked the Plan to pre-approve Alymsys in combination with FOLFOX. You say that this is for 
chemotherapy. The Plan denied your request. The Plan says you do not have any stated contraindications to the 
preferred products, nor have you tried any of the preferred agents. The Plan also says the provider does not 
provide a rationale for use of the non-preferred product for safety or efficacy. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Alymsys in combination with 
FOLFOX. Our reviewer says that you do not meet the coverage criteria for Alymsys in combination with 
FOLFOX. Our physician reviewer found the provided records do not indicate that you have tried and failed the 
Plan's preferred step one alternative. The record does not indicate that you have a contraindication to, or would 
have an adverse effect from the Plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Alymsys in combination with FOLFOX have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Alymsys (Q5126) in combination with FOLFOX 
(leucovorin (J0640), fluorouracil (J9190), and oxaliplatin (J9263)).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker, enclosed, four sided framed, rigid, or folding, 
wheeled with posterior seat (E0144). 
 
You asked the Plan to pre-approve a walker. You say that you suffer from a medical condition and the walker 
will help you with gait training. You have a standard walker but are experiencing falls. The Plan denied your 
request. The Plan says the requested walker has not been established and is not medically reasonable or 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an enclosed frame walker will be denied as not 
reasonable and necessary. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a walker have not been met. Medicare rules say that the medical necessity for an enclosed frame 
walker has not been established and will be denied as not reasonable and necessary. Therefore, we decided that 
the Plan does not have to pre-approve a walker, enclosed, four sided framed, rigid, or folding, wheeled with 
posterior seat (E0144).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve the power seat elevation feature. You say that the requested item is 
medically necessary. The Plan denied your request. The Plan says that the power seat elevation feature is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The power seat elevation feature does not serve a purpose that is primarily medical in nature and is not 
covered. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation feature 
(E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for the enrollee to return to 
baseline functional status. The Plan denied your request. The Plan says the IRF services you are requesting do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the skilled care has been beneficial in 
improving the enrollee's functional abilities. You say that the enrollee needs more visits in order to be able to 
make further gains and improvements towards achieving their goals. The Plan denied your request. The Plan says the additional physical therapy visits are not medically necessary. The Plan approved four visits to 
establish a home exercise program and the remaining 14 visits are not approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the services are 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 therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 
additional physical therapy visits.
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 IRF care is medically necessary, and the 
enrollee's meets all criteria. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility, home 
with 24-hour caregiver and home health services. 
 
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 had an uncomplicated hip fracture repair. The enrollee does not require 
intensive rehabilitation to recover from an uncomplicated hip fracture. The enrollee has impaired ability to 
participate in intensive rehabilitation as they are toe-touch weight bearing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive inpatient rehabilitation 
with daily physician oversight. The Plan denied your request. The Plan says the services the enrollee needs can 
be provided safely in another setting such as a skilled nursing facility, home with home health services or home 
with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that they 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF. The enrollee 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for a CT scan and an ultrasound provided on 
November 16, 2022, and November 30, 2022. 
 
You asked the Plan to reduce the copayments for a CT scan and an ultrasound. You say that you disagree with 
the copayments charged for services rendered. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays.  
 
You have been asked to pay a total copayment of $244.81 for a CT scan and an ultrasound. This total includes 
a $125 copayment for a CT scan and $119.81 for an ultrasound, which is less that the standard $125 
copayment. These items/services fall within the outpatient diagnostic tests benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the copayments for a CT scan and an ultrasound provided on November 16, 2022, and 
November 30, 2022.