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

 
We decided that the Plan has to pre-approve intensity modulated treatment delivery. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show that stereotactic ablative radiotherapy (SABR) has been 
considered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that it is plausible that intensity modulated radiation therapy would afford a clinically meaningful 
benefit. Ten fractions of treatment appear to be within accepted standards 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve intensity modulated treatment delivery.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomographic (CT) angiography of the head 
(70496) and CT angiography of the neck (70498). 
 
You asked the Plan to pre-approve CT imaging of the head and neck. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the requested imaging services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 CT imaging of the head and neck. Our 
reviewer says that the requested imaging services are not medically necessary in this case. Our physician 
reviewer found that the provided records included only a single visit at which time the enrollee was noted to 
have symptoms of Parkinsons Disease. In general, the requested imaging is not commonly or customarily 
performed for the evaluation of Parkinsons Disease. There were no records provided indicating that the 
enrollee has a condition for which performance of the requested studies would otherwise be considered to be 
reasonable and necessary. Rather, the requested studies cannot be said to otherwise be consistent with the 
generally accepted standards of practice and or care. As such this request would not be 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 CT imaging of the head and neck have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomographic (CT) angiography of the head (70496) and CT 
angiography of the neck (70498).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage for continuous positive airway 
pressure (CPAP) device (E0601). 
 
You asked the Plan to pre-approve the CPAP device. You say that these services should be covered due to the 
enrollee being compliant. The Plan denied your request. The Plan says the request is not reasonable and 
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 CPAP device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has severe obstructive sleep apnea and CPAP at 15 was shown to be 
effective on PAP titration. However, usage data show the enrollee is not using the device enough to be 
effective, or to meet the minimum Medicare criteria of at least 4 hours per night for at least 70% of nights. Data 
for July-August 2022 show roughly 40% of nights with at least 4 hours. There has been no subsequent clinical 
visit to address the compliance issue.  
 
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 CPAP device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued coverage for continuous positive airway pressure (CPAP) device (E0601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the positioning cushion/pillow/wedge, any shape or 
size, includes all components and accessories (E0190). 
 
You asked the Plan to pre-approve the donut cushion. You say that you hurt your tailbone and is in a lot of 
pain. You cannot sit on anything without pain. The Plan denied your request. The Plan says this item 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 item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the positioning cushion/pillow/wedge, any shape or size, 
includes all components and accessories (E0190).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visits. You say that you want to see a Nephrologist in Cleveland 
Ohio for a second opinion regarding your health situation. You do not feel that you are getting better with your 
current doctors at the current location. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 
the outpatient office visits to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation beyond the Plan's 20-
trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation. The 
Plan denied your request. The Plan says you have exhausted your transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The Plan provided documentation showing that 20 transports have been covered. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional routine transportation beyond the Plan's 20-trip limit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on April 14, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that it is mandatory to report a clinical trial number on 
claims for items/services provided in clinical trials/studies/registries. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the clinical trial 
number. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on April 
14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmological services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve ophthalmological services. You say that you would like to receive the 
requested services from the OON provider because you are familiar with and trust the provider. The Plan 
denied your request. The Plan says rules for coverage for OON services have not been met. 
 
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 
ophthalmological services to be provided by an OON provider.
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 is stable and needs an 
LTACH level of care. You say that the enrollee's needs exceed the capabilities of a skilled nursing facility level 
of care. The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the 
enrollee can receive the care they need in the current hospital setting. 
 
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 there is no evidence that the enrollee requires services that are not currently available 
at their current acute setting. The enrollee can remain at the current acute care hospital until no acute services 
are required. The enrollee can then be discharged to a lower level of care for any ongoing long term care needs. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a routine eye exam. 
 
You asked the Plan to pre-approve a routine eye exam. You say that the services are necessary. The Plan 
denied your request. The Plan says the benefit has been exhausted. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a routine eye exam and contact lens fitting exam once every 2 years. 
 
We looked at the file and the Plan's rules. Specifically, you received an eye exam on August 24, 2021. 
Therefore, you are not eligible for Plan coverage for a routine eye exam at this time. Based on this information, 
we decided that the Plan's rules for coverage of a routine eye exam have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a routine eye exam.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 
You asked the Plan to pre-approve a sleep study. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies are only covered for certain indications. 
 
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 
the documentation does not support that the requested sleep study is medically reasonable or necessary. Our 
physician reviewer found you are undergoing evaluation for gastric sleeve surgery. Based on the medical 
records provided there is no documentation that the sleep study at issue in this case meets all Medicare criteria 
for medically reasonable and necessary. The provided records do not document a diagnosis or signs or 
symptoms of obstructive sleep apnea (Epworth Sleepiness Scale score of three), narcolepsy, impotence or a 
parasomnia as required by Medicare's Local Coverage Determination. Therefore, you do not meet criteria for 
the requested sleep study. 
 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.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo solution 6mg/0.05ml. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the step therapy guidelines, the plan can approve Avastin. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the plan requires a 
trial of Bevacizumab/Avastin before they will approve the requested drug. In this case, the patient has not tried 
and failed the required drug. There is no documentation provided indicating that the plans required drug would 
likely be less effective and/or likely have adverse effects for the 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo solution 6mg/0.05ml.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the requested Watchman device procedure is not indicated. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's 
necessary hospital 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 pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a multi-axial rotation unit (L5986). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this exceeds the enrollee's needs and cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Our doctor found that no medical records have been submitted. The plan has not 
substantiated their denial. There is no way to see if this item would truly exceeds the enrollee's medical needs. 
Therefore, we decided that the Plan has to pre-approve a multi-axial rotation unit (L5986).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this procedure is investigational and non-covered. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested Intracept procedure is experimental. More research is needed to show 
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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies 
rendered on December 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately paid. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services.  
 
We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was 
under inpatient status. Payment for these services is included in the payment to the facility. Therefore, we 
decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies rendered on 
December 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myobloc. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has Parkinson's disease 
with sialorrhea. He has not tried and failed the Plan's required drugs, Xeomin and Botox. The records do not 
show that the required drugs would be contraindicated or less effective; therefore, Myobloc is 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 Myobloc.