Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on November 28, 2022. 
 
You asked the Plan to pay for the air ambulance services. You say that you refused the helicopter services, but 
they took you anyways and you are unable to afford this bill. The Plan denied your request. The Plan says a 
ground ambulance could have transported you to an appropriate facility more quickly.  
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found you fell in 
your bathroom and were suspected of having a hip fracture. Such injuries are common and do not warrant an 
air ambulance. You should have been taken by ground ambulance to the nearest hospital for initial evaluation. 
If transfer to a larger or specialty facility was necessary, it could have then been arranged. The air medical 
transport was not medically necessary or reasonable. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on November 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intensity-Modulated Radiation Therapy (IMRT) (77014, 77385, 
77387). 
 
You asked the Plan to pre-approve IMRT. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that there is no high-quality evidence that this type of radiation therapy is needed or 
effective for the enrollee's cancer. 
 
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 IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from 
high dose exposure. Advantages of IMRT are to reduce the dose to the heart, lungs, skin and contralateral 
chest. IMRT can also improve the dose homogeneity of the treatment volume, and therefore reduce the hot 
spots that are often seen in the lateral chest wall. For enrollees with an intact breast after resection, IMRT has 
been shown to improve skin and breast toxicity. For post-mastectomy radiation, IMRT has been shown to 
significantly reduce the dose-volume exposure of the ipsilateral lung and (for left sided breast cancer) the heart. 
It is plausible that with this enrollees plan to treat the whole breast and regional nodes, that IMRT would be 
necessary for dose homogeneity. In summary, it is safe to say that IMRT is not experimental, but rather a 
useful tool available to radiation oncologists to potentially reduce toxicity and improve the lung and skin dose 
distributions. The decision is favorable as IMRT would be furnished in accordance with accepted standards of 
medical practice.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
Intensity-Modulated Radiation Therapy (IMRT) (77014, 77385, 77387).  
 
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: 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 requesting reconsideration based on medical 
necessity. The Plan denied your request. The Plan says the enrollee does not meet the criteria for an IRF 
admission.  
 
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 nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gocovri. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gocovri.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT) (77386x5). 
 
You asked the Plan to pre-approve IMRT. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that there is no high-quality evidence that this type of radiation therapy is needed or 
effective for the enrollee's cancer. 
 
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 IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is being offered adjuvant radiation to the liver (post-resection of an intrahepatic 
cholangiocarcinoma). A screen capture of the treatment plan shows spherical target volume close to the 
stomach/esophagus. The 2023 National Comprehensive Cancer Network (NCCN) guidelines do not address 
indications for IMRT simply stating: Postoperative radiation therapy (RT) using conventional 3D conformal 
RT (Three-Dimensional Conformal Radiation Therapy (3D-CRT)) or IMRT is an option. For this case, while 
there is a plan, though no plan comparison. Nevertheless, the proximity of the target volume to normal tissues 
supports the need for IMRT when used for definitive chemoradiation. The neighboring gastrointestinal (GI) 
organs are susceptible to radiation induced toxicity which IMRT can reduce. Our reviewer suspects that a non-
IMRT based dynamic conformal arc plan would results in excellent target coverage and organ tissue sparing 
(given the spherical target volume). Nevertheless, IMRT in this clinical situation is an accepted standard of 
medical practice. The decision is favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
intensity-modulated radiation therapy (IMRT) (77386x5).  
 
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: Favorable

 
We decided that the Plan has to pay for the computed tomography (CT) services described by code 71260-26 
performed on date of service April 14, 2023. 
 
You asked the Plan to pay for 71260-26. You say that 71260-26 should be paid as billed because it is supported 
in the documentation. The Plan denied your request. The Plan says that 71260-26 is denied because another 
provider reported an interpretation of the CT for which payment was already allowed. 
 
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 rules also say that a professional component billing of a diagnostic procedure based on a review 
of the findings, without a complete, written report similar to that which would be prepared by a specialist in the 
field, does not meet the conditions for separate payment of the service. The rules also say that if imaging 
studies are repeated during the course of a radiological encounter due to substandard quality or need for 
additional views, only one unit of service for the appropriate code may be reported 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the denial reason cited by the Plan is not applicable in this case as 
the Plan has not provided a rule which states that a second interpretation done for the same CT scan is not 
payable. Since the appealed claim in this case is a secondary interpretation of the same CT scan by a different 
radiology group, the emergency department radiology rules cited the Plan do not apply. The comparative 
imaging rule cited by the Plan also does not apply because the claim in question is not for repeat images to 
compare to the first. It is instead another opinion on the same images previously taken. As such, the Plan has 
not provided an adequate rationale for their denial of code 71260-26. Therefore, we decided that the Plan has to 
pay for the computed tomography (CT) services described by code 71260-26 performed on date of service 
April 14, 2023.  
 
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: 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 meets the criteria for an IRF admission 
and should not be denied. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical problems, including a prior history of stroke, are stable and at 
their baseline. The enrollee requires physical and occupational therapy services but does not need to be seen by 
a rehabilitative medicine specialist three times weekly.  
 
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 requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute inpatient 
rehabilitation setting have 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are elderly, and this is the best place for you to 
receive care. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron.  
You asked the Plan to pre-approve the medication. You say that this is necessary for the enrollee. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although oral anti-emetic drugs such as ondansetron may sometimes be covered by 
Medicare Part B, the requested use of ondansetron does not fall within Part B coverage because it is not being 
administered as part of a cancer chemotherapy regimen. Therefore, we decided that the Plan does not have to 
pre-approve ondansetron.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation for your medical appointments. The Plan denied your request. The Plan says your benefit only 
allows 24 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 84.5 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, heavy duty, extra wide, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type of side rails, with 
mattress (E0303). 
 You asked the Plan to pre-approve a heavy-duty hospital bed. You say that the enrollee is currently sleeping in 
a chair because his current mattress has coils coming out of it and is very cheap. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for approval of the requested hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed is covered if the 
beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 
350 pounds but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty hospital bed have not been met. Specifically, the records show that the enrollee does 
not meet the weight requirement for the requested heavy duty hospital bed. Therefore, we decided that the Plan 
does not have to pre-approve a hospital bed, heavy duty, extra wide, with weight capacity greater than 350 
pounds, but less than or equal to 600 pounds, with any type of side rails, with mattress (E0303).
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee may benefit from ongoing physical and occupational therapy, 
but the services they need can be provided safely in other settings such as skilled nursing facility (SNF).  
 
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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement. However, the 
documentation doesnt support that they would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehab services 15 hours a week, under the supervision of a physician with at least three visits weekly to regain 
or maintain their functional status.  The enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.