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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.

You asked the Plan to pre-approve the compression stockings. You say that your veins swell, and you are in
pain. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6545 are
noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6545.
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 skilled nursing is not an appropriate safe level of
care at this time. The Plan denied your request. The Plan says the enrollee does not require an intensive and
coordinated interdisciplinary approach to rehabilitation care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Her
medical problems are stable. She does not require treatment by multiple therapies in an intensive rehabilitation
therapy program. While she has a need for physical and/or occupational therapy, there is no documentation of a
need for an intensive rehabilitation program.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-preferred glucometer brand.
You asked the Plan to pre-approve the requested item. You say that you do not want to use a different glucose
meter. The Plan denied your request. The Plan says you must choose a preferred glucometer brand.
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as
preferred.
We looked at the file and the rules. The file shows that you requested a non-preferred brand durable medical
equipment. The Plan contract says that non-preferred brands are not covered. The file does not provide
sufficient documentation that shows you are unable to use a preferred brand device. Therefore, we decided that
the Plan does not have to pre-approve a non-preferred glucometer brand.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Ablysinol infusion.
You asked the Plan to pre-approve Ablysinol. You say that the requested treatment is a medical necessity for
the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the
requested treatment is experimental and not medically accepted.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 Ablysinol. Our reviewer says that the
requested treatment is not medically reasonable and necessary in this case. Our physician reviewer found that
the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's
condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the
requested drug in the enrollee's clinical situation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ablysinol have not been met. Therefore, we decided that the Plan does not have
to pre-approve treatment with Ablysinol infusion.
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 you cannot go home and need to go to an IRF to
recover fully. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You
can safely receive the services you need in an alternate setting.
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 based on the documentation provided, you do not require the intensity of services
provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services
with regular physician evaluation. Your care needs can be met in 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: 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 you are not in a condition that you can be moved to
another facility. The Plan denied your request. The Plan says your needs can safely be met at a lower level of
care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that you are at a minimal assist level for walking, contact guard assist for bed mobility and toilet transfers, and
minimal assist for upper body activities of daily living. You do not require the intensity of services provided at
an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide office visits and follow up care to be provided.
You asked the Plan to provide office visits. You say that the request was for an out-of-
network physician. The Plan denied your request. The Plan says physician has opted out of Medicare and
provided a list of In-Network providers.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal are not an emergency situation by a provider who has opted out of the
Medicare program. Therefore, we decided that the Plan does not have to provide office visits and follow up
care to be provided.
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 needs daily physician care and intensive therapies that cannot be provided in a skilled nursing facility or home health. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of the enrollee's medical, nursing, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee does have a need for physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve a PET scan. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET scan. Our reviewer says that the
documentation does not support that the requested PET scan is medically reasonable or necessary. Our
physician reviewer found the enrollee has an elevated prostate-specific antigen (PSA) of 18.8 ng/mL. The
enrollee was evaluated with ultrasound guided needle biopsy of the prostate on June 26, 2021. Pathology
revealed stage T1c, Gleason's grade 4+4 adenocarcinoma involving 1 of 6 core biopsies. Bone scan was
negative for bone metastasis. Computed tomography (CT) scan revealed a 3 cm right inguinal lymph node. The
enrollee has active right foot osteomyelitis which could cause inguinal adenopathy. A PET scan is not
medically necessary for this enrollee. Biopsy of the right inguinal lymph node will be needed regardless of the
PET scan findings.
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 PET scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Fluid Flow/Fluid GF injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary for treatment of chronic pain. The Plan denied your request. The Plan says this is considered experimental and investigational for orthopedic uses.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational therapy and therefore is considered 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 injection have not been met.
Therefore, we decided that the Plan does not have to pre-approve a Fluid Flow/Fluid GF injection for the enrollee.
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 you need inpatient rehabilitation services to be able
to walk again and build strength. The Plan denied your request. The Plan says the criteria for admission to an
IRF are not met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found based on the limited documentation provided, you do not require the intensity of
services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative
services with regular physician evaluation. The requested IRF 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor kit.
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor kit. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested
device.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this
information, we decided that Medicare rules for coverage of a Freestyle Libre 14 day sensor kit have not been
met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor kit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the most appropriate setting
for the enrollee to continue treatment. The Plan denied your request. The Plan says the denial of authorization
for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee appears to be improving and should only require short-term additional
acute care services. Care can be safely received at the current facility until a lower level of care is appropriate.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
You asked the Plan to pre-approve a complete upper denture. You say that your original dentures were
destroyed and need to be replaced. The Plan denied your request. The Plan says you have exceeded the
frequency limit for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a complete
upper denture once every five plan years.
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper
denture was previously covered on November 30, 2020. Based on this information, we decided that the Plan's
frequency limit for coverage of a complete upper denture would be exceeded with the requested service.
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital surgery provided on
September 29, 2021.
You asked the Plan to waive the copayment for the surgery services. You say that the services provided were
done in an office and there should not be a copayment for outpatient. The Plan denied your request. The Plan
says the provider billed as an outpatient facility and the proper copayment was applied.
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 $395
copayment for In-network per visit Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers.
You have been asked to pay a $395 copayment for surgery services. The surgery services falls within the
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers
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 waive the copayment for an outpatient hospital surgery
provided on September 29, 2021.
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 acute rehab will optimize her level of functioning
prior to returning home. The Plan denied your request. The Plan says the enrollee does not have complex
nursing, medical, or rehabilitation needs.
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 physician reviewer found
that the enrollee was admitted to the acute care hospital for back pain and was treated non-surgically for a
compression fracture. Her medical problems are stable. She does not require treatment by multiple therapies in
an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational
therapy, there is no documentation of a need for an intensive rehabilitation program.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gastroenterology visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist visit. You say that you disagree with this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network specialist.
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 gastroenterology visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5225).

You asked the Plan to pre-approve an upper partial denture. You say that the service is medically necessary.
The Plan denied your request. The Plan says the service at issue 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 Plan's 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 an
upper partial denture (D5225).