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

 
We decided that the Plan has to pre-approve 3 fractions of electron beam radiation therapy. 
 
You asked the Plan to pre-approve 3 fractions of electron beam radiation therapy. You say that this procedure 
is medically necessary for treating the enrollee's condition. The Plan denied your request. The Plan says that 
this treatment is not considered standard practice for the enrollee's condition. 
 
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 3 fractions of electron beam radiation 
therapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary 
in this case. Our physician reviewer found that radiation is a standard approach to the treatment of skin cancer. 
This patient previously received standard electron beam radiation (the dose and fractionation are not described 
in the case records, nor were the exact dates of treatment- other than stating that the treatment was ~70 days 
prior to her April 12, 2022, appointment). Because of residual disease she is being offered a course of salvage 
radiation - presumably also with electron beam radiation (billing request for complex isodose plan and 
dosimetry calculation). The dose and fractionation were chosen to maximize tumor control with acceptable 
risks given the prior radiation therapy. Such treatment appears 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 3 fractions of electron beam radiation therapy have been met. Therefore, we 
decided that the Plan has to pre-approve 3 fractions of electron beam radiation therapy.  
 
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 additional home health aide hours. 
 
You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan 
denied your request. The Plan says it is appropriate to reduce the hours from 56 hours per week to 30 hours per 
week. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 additional hours. Our reviewer says 
that the requested additional hours are not medically reasonable or necessary. Our physician reviewer found 
you are not homebound. You do not have documented skilled nursing, such as intravenous (IVs), complex 
wound care, new tube feeds, new ostomy, etc. These services are not shown to be medically necessary to assist in the treatment of illness or injury. As such, the requested additional hours 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 additional hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health aide hours.
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 a short IRF stay for improved 
functional independence, mobility/transfers and balance and strength. The Plan denied your request. The Plan 
says IRF is not medically necessary and the enrollee's needs can be met at a lower level of care such as in a 
skilled nursing facility (SNF), at home with home health services or at 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 that the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation 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 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 Opdivo (J9299). 
 
You asked the Plan to pre-approve Opdivo. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity rules for use of the requested drug 
have not been met because the use at issue is off-label and not medically supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Opdivo. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Opdivo is not FDA-approved for the enrollees diagnosis. The use is not supported by one of 
the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Opdivo (J9299).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that a capsule endoscopy should be 
covered for the enrollee. The Plan denied your request. The Plan says the documentation does not show 
evidence of bleeding and the enrollee's hemoglobin and hematocrit are normal. The Plan also says that they 
have determined that there is no indication in the medical record that the enrollee has gastrointestinal bleeding 
or suspected missed small bowel lesion. 
 
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 a wireless capsule endoscopy. Our 
reviewer says that the wireless capsule endoscopy is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the likelihood of missed small pathology in the enrollee is low, given the 
evaluation to date and the enrollee's normal hemoglobin and hematocrit. Our reviewer also found that no data 
was presented to indicate that the enrollee's iron deficiency reflects high suspicion of gastrointestinal blood loss 
to warrant capsule endoscopy as requested. 
 
 
  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 wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wireless capsule endoscopy (91110).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (96132, 96133, 96137, 
96136). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that there is concern that this enrollee 
has dementia, and these services are necessary to assess the enrollee's cognitive profile, and if he has dementia, 
help to clarify what form. The Plan denied your request. The Plan says these testing services are not medically 
necessary in this case. 
 
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 neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee claims having memory impairment documented as the 
enrollee has been forgetful of his wifes name and is becoming more paranoid for thinking that people are in 
the house. This neurologic exam showed he was oriented to self and place but less oriented to time. Utilizing 
the criteria for neuropsychological testing, this enrollee does not meet the criteria as he is not showing severity 
of symptoms that would warrant this type of diagnostic treatment. The request for neuropsychological testing is not medically necessary or reasonable as information presented is sufficient for the decision-making process 
for treatment of 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 neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (96132, 96133, 96137, 96136).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus augmentation via a vertical approach (D7952). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this is not a covered benefit. 
 
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 pre-approve sinus 
augmentation via a vertical approach (D7952).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (K0553) 
provided on December 29, 2021. 
 
You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that you would like this 
claim reprocessed based on the documentation submitted. The Plan denied your request. The Plan says they 
were unable to obtain a valid proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the medical records that are provided do not indicate the enrollees provider discussed 
the medical necessity of the ordered equipment with the enrollee. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the therapeutic continuous glucose monitor (K0553) provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture (97810, 97811), provided on December 17, 
2021. 
 
You asked the Plan to pay for the acupuncture. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this service is not covered when provided by a licensed acupuncturist, not a 
physician; this provider is not supervised by any physician, PA, or NP/CNS. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, this provider is not supervised by any physician, PA, 
or NP/CNS. Therefore, we decided that the Plan does not have to pay for the acupuncture (97810, 97811), 
provided on December 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
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 the service 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 the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. 
 
 
 
  
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 the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
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. The enrollee 
was admitted after being found down with a cerebral infarct. The record indicates that the enrollee has 
ventilator associated pneumonia and requires ongoing acute care services. The enrollee continues to receive 
acute care services, and these have not been denied. The medical record does not indicate that the enrollee 
requires services that he is not currently receiving but that would be available at the LTACH facility. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 6, 2021, to 
March 3, 2021. 
 
You asked the Plan to pay for the home health services. You say that you have sent 3 claims together. You say 
that this is the only one to be denied for late RAP. You also say that this claim should have been paid too. The 
Plan denied your request. The Plan says the RAP claim was not submitted timely. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, February 6, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from February 6, 2021, to March 3, 2021.
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 LTACH services. You say that LTACH admission is medically necessary 
for the enrollee. The Plan denied your request. The Plan says that due to the multiple untreated medical issues 
of the enrollee, he is not stable to move to an LTACH level of care. 
 
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 there are no services available at the LTACH that the enrollee requires, that are 
not available at the health care setting being offered currently. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right prosthetic leg with an advanced foot feature and 
axial rotational unit. 
 
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 request for a K3 foot does not meet Medicare criteria as 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided records do not support that you are or soon will be a K3 level ambulator. You have not 
ambulated since September 2021 when the below-knee amputation (BKA) was performed; you also have a left 
transmetatarsal amputation. The records do not support that you will soon be doing more than simple walking, 
that you will be walking for long-distance at variable rates daily or that you will be regularly walking on 
uneven terrain or regularly using stairs. 
 
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 a right prosthetic leg with an advanced foot feature and axial rotational unit.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from June 17, 2021, to 
October 31, 2021. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services provided were reasonable, 
following a hip fracture in an elderly person who was self-ambulatory prior to their fall. You also say that the 
daily rehabilitation services were helping the enrollee be more ambulatory and assist in her own transfer. The 
Plan denied your request. The Plan says the enrollee was informed that these services would not be covered and 
chose to be admitted as self-pay.  
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from June 17, 2021, to October 31, 2021.