Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right below the knee prosthetic and related supplies to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON knee prosthetic and related supplies. You say that the records 
provided support the need for the items in dispute. The Plan denied your request. The Plan says the 
items/services needed are available from a provider within the 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 
a right below the knee prosthetic and related supplies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you should not be responsible to pay this. The Plan 
denied your request. The Plan says you must receive your care from a network provider. 
 
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 office visit provided on April 28, 2022, by an 
out-of-network (OON) provider.
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. You say that IRF care is medically necessary. 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 does not have complex or intensive rehabilitation needs. Hip fracture 
rehabilitation is routinely provided at levels of care other than 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 IRF admission and services.
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 hip fracture rehabilitation does not require frequent physiatry oversight or 
intensive therapy. The enrollee has no complicating factors and is tolerating therapy. 
 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: 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 device is needed. The Plan denied your 
request. The Plan says the requested device does not meet the requirements for approval. 
 
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 enrollee was recently hospitalized 
with sepsis from a perianal abscess, and ABGs were consistent with acute on chronic hypercarbic respiratory 
failure. PFTs show combined restrictive and obstructive lung disease. Obesity-hypoventilation is also likely 
playing a role. The enrollee may benefit from BiPAP with AVAPS during sleep.  But 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is not ready to be released. You also say 
that the enrollee cannot sit up and walk on his own. The Plan denied your request. The Plan says skilled 
nursing facility services are being discontinued because continuation of SNF is not medically necessary and 
does not meet Medicare guidelines. 
 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 member does not require the services on an inpatient basis, or only in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the hip x-rays (73502) and office visit (99203) provided on May 26, 
2022. We also decided that the Plan does not have to pay for the hip injection (20610) provided on May 26, 
2022.  
 You asked the Plan to pay for a hip injection (20610), hip x-rays (73502), and an office visit (99203) provided 
by an out-of-network provider on May 26, 2022.. You say that authorization for services was granted. The Plan 
denied your request. The Plan says that there is no authorization on file for the services. 
 
We decided that the Plan has to pay for the hip x-rays (73502) and office visit (99203) provided on May 
26, 2022.  
 
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. In this case, authorization was received for certain services 
under authorization #138101936. The listed services include the x-rays and office visit. Therefore, we decided 
that the Plan has to pay for the hip x-rays (73502) and office visit (99203) provided on May 26, 2022.  
 
We also decided that the Plan does not have to pay for the hip injection (20610) provided on May 26, 
2022. 
 
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. In this case, authorization was received for certain services 
under authorization #138101936. However, the included services do not include the arthrocentesis/injection. 
Therefore, we decided that the Plan does not have to pay for the hip injection (20610) provided on May 26, 
2022. 
 
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: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from August 12, 2021, through 
August 30, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that this claim has been billed with an 
invalid Core Based Statistical Area (CBSA). 
 
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. In this case, the Plan has not clarified why the CBSA code that has been billed is 
invalid. There is no rule cited that indicates that the billed CBSA code should be considered invalid. Therefore, 
we decided that the Plan has to pay for the home health services provided from August 12, 2021, through 
August 30, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this procedure is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
requested procedure is considered 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 the Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that this 69-year-old female was being treated for spinal stenosis of the 
lumbar region with neurogenic claudication. She presented with right-sided low back pain in the lateral aspect 
of her right thigh. The pain is present with standing and walking.  The exam reveals reflexes at 0 in the bilateral 
patella and Achilles. Strength and sensation are intact. There is a positive Stoops test.  
 
In this case, current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Minuteman procedure at L3-4, in 
this case, 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 the Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty services. 
 
You asked the Plan to pre-approve blepharoplasty services. You say that the clinical documentation supports 
the need for the requested services. The Plan denied your request. The Plan says the requested services are not 
medically necessary because the records show that the enrollee does not have physical signs represented in 
color photographs. 
 
The Plan must follow Medicare rules. Medicare rules say that color photographs are required to support upper 
eyelid surgery as medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of blepharoplasty services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve blepharoplasty services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the combination of Thiamine, Pyridoxine, 
Cyanocobalamin and Levocarnitine for the treatment of chronic pain. 
 
You asked the Plan to pre-approve the combination of Thiamine, Pyridoxine, Cyanocobalamin and 
Levocarnitine. You say that you would like reconsideration because the requested vitamins are medically 
necessary. The Plan denied your request. The Plan says the requested use of vitamins is considered 
experimental. 
 
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 the combination of Thiamine, 
Pyridoxine, Cyanocobalamin and Levocarnitine. Our reviewer says that the requested use of vitamins 
(Thiamine, Pyridoxine, Cyanocobalamin, Levocarnitine) is not Food and Drug Administration-approved for unspecified chronic bilateral lower extremity pain. The requested use of vitamins is also not indicated, 
supported or recommended in any of the compendia. Our physician reviewer found the provided records do not 
document any laboratory reports showing any vitamin deficiencies. The requested use of vitamins does not 
meet Medicare criteria for safe and effective and otherwise reasonable and necessary for 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 combination of Thiamine, Pyridoxine, Cyanocobalamin and Levocarnitine have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the combination of Thiamine, 
Pyridoxine, Cyanocobalamin and Levocarnitine for the treatment of chronic pain.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on February 23, 2022 to May 18, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you were under the impression that all the 
claims would be approved. You say that you later learned that this provider was out-of-network. The Plan 
denied your request. The Plan says that you must use in-network providers to get your medical care and 
services. 
 
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. The Plan did not provide the correct 2022 Evidence of Coverage document. 
Therefore, we decided that the Plan has to pay for laboratory services provided on February 23, 2022 to May 
18, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health occupational therapy services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the coverage criteria is not met. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that there are no 
documented ongoing home health occupational therapy needs. You are functioning at your baseline. There has 
been ample time to assess durable medical equipment needs and to educate and train family and caregivers as 
needed. The requested ongoing home health occupational therapy services are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health occupational therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on  
November 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the enrollee must receive your care from a 
network provider. 
 
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 chiropractic manipulative treatment provided on 
November 2, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home physical therapy (PT) and occupational 
therapy (OT) services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the Medicare criteria are not met, and medical necessity is not established. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you do not have ongoing home health therapy needs. You appear to have reached a plateau in 
function given your chronic disability. Ample services have been provided to complete durable medical 
equipment assessments, and to educate and train family and caregivers. The requested ongoing services are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued home physical therapy (PT) and occupational therapy (OT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, laboratory services, venipuncture, and an 
EKG provided on May 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, laboratory services, venipuncture, and an EKG. You say that you 
were out of state at the time, and this should be covered. The Plan denied your request. The Plan says you must 
receive your care from a network provider 
 
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 office visit, laboratory services, venipuncture, 
and an EKG provided on May 25, 2022, by an out-of-network (OON) provider.