Persius/hicric huggingface dataset:
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 is not receiving anymore therapy and is 
currently sitting not being able to strengthen themselves. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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 continued inpatient mental health treatment.  
 
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 services can be safely provided in other settings. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 it was not 
expected this enrollee would improve in a reasonable period of time for the dates in question as she did not 
have suicidal or homicidal ideation, auditory or visual hallucinations. The patient was compliant with treatment 
while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question. The health plans denial of continued inpatient psychiatric services 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient mental health treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endosteal implants (D6010 x3) provided on March 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
rendering provider does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for endosteal implants (D6010 x3) provided 
on March 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis, sacroiliac (SI) joint, percutaneous or 
minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when 
performed, and placement of transfixing device (27279). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because the enrollee's records show 
they do not have failure of bracing, and the degree of relief experienced from the enrollee's recent injection 
procedures is not clear. The Plan states the enrollee's computed tomography (CT) imaging shows degenerative 
changes and moderate to severe foraminal narrowing that can be causing the enrollee's pain. 
 
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 service. Our physician reviewer 
found there is no Si joint instability fracture or lesion. SI joint fusion degen back pain is experimental. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the arthrodesis, sacroiliac (SI) joint, percutaneous or minimally invasive (indirect 
visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device (27279).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent ambulance transportation services 
(A0382, A0425, A0428) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve non-emergent ambulance transportation services. You say that these 
transportation services are medically necessary. The Plan denied your request. The Plan says the requested 
services can be provided by a specific ambulance company who is contracted with the Plan. 
 
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 
non-emergent ambulance transportation services (A0382, A0425, A0428) to be provided by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records and current peer-reviewed 
medical literature do not document that the Cala Trio device has been shown in controlled studies in a 
Medicare-approved journal to result in sustained, long-term health benefits in patients with essential tremor. 
The services are therefore not reasonable or medically necessary at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Cala Trio device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supply allowance for nonadjunctive, nonimplanted 
continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply (A4239) and 
nonadjunctive, nonimplanted continuous glucose monitor (CGM) or receiver (E2103). 
 
You asked the Plan to pre-approve the continuous glucose monitor (CGM) and supplies. You say that you 
could monitor your diabetes better with a CGM . The Plan denied your request. The Plan says your request is 
not medically necessary because your records do not show that you are taking insulin or documentation of 
multiple hypoglycemic events with where your blood sugar was less than 54. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the continuous glucose monitor (CGM) 
and supplies. Our physician reviewer found the review indicates that the enrollee has diabetes but is not 
maintained on insulin therapy. The review has determined that the enrollee has diabetes mellitus and the 
enrollee's treating practitioner has conclude that the enrollee or their caregiver has sufficient training using the 
CGM prescribed, as evidenced by providing a prescription. The requested CGM is not prescribed in accordance 
with its Food and Drug Administration (FDA) indications for use as the enrollee is not insulin treated. The 
enrollee does not have a history of problematic hypoglycemia. The documentation provided did not support 
that within 6 months prior to ordering the CGM, the treating physician had an in-person or Medicare-approved 
telehealth visit with the enrollee to evaluate their diabetes control and determine whether criteria for coverage 
are met. 
 
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 continuous glucose monitor (CGM) and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve supply allowance for nonadjunctive, 
nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply 
(A4239) and nonadjunctive, nonimplanted continuous glucose monitor (CGM) or receiver (E2103).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi (J0174). 
 
You asked the Plan to pre-approve Leqembi. You say that this drug is necessary to treat the enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare criteria for this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Leqembi. Our reviewer says that the 
requested drug is not medically necessary in this case. Our physician reviewer found that the enrollee has 
moderate Alzheimer's disease by studies including imaging, cerebrospinal fluid (CSF) analysis and Mini-
Mental State Examination (MMSE) of 15/30. The enrollee is not a participant in a CMS-approved trial or 
registry. The review has determined that the documentation does not support that the Leqembi is medically 
reasonable and necessary for the patient. The documentation does not support that the Leqembi is safe and 
effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi (J0174).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin or have a documentation of recurrent level two hypoglycemic events that persist despite multiple 
attempts to adjust medications and/or modify the diabetes treatment plan. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. There is no arterial blood gas done while stable to confirm chronic carbon dioxide (CO2) retention. 
If that is present, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with volume 
assurance during sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that 
can be provided with 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve labial veneer (porcelain laminate) - laboratory. 
 
You asked the Plan to pre-approve labial veneer (porcelain laminate) - laboratory. You say that the services are 
necessary. The Plan denied your request. The Plan says the services are not covered. 
 
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 
labial veneer (porcelain laminate) - laboratory.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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/CT scan. Our reviewer says that 
the services are medically necessary. Our physician reviewer found 3 separate malignancies and a prior 
positive PET/CT scan is a valid indication for a followup PET/CT scan, especially after a negative 
colonoscopy. 
 
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/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan 
from the skull base to mid-thigh (78815).  
 
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 open implantation of hypoglossal nerve neurostimulator 
array, pulse generator, and distal respiratory sensor electrode or electrode array (64582), generator, 
neurostimulator (implantable), nonrechargeable (C1767) and patient programmer, neurostimulator (C1787). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because your records show you 
have a polysomnogram (PSG) showing 88.7 apnea-hypopnea index (AHI) per hour. 
 
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 physician reviewer 
found there is no documentation that the hypoglossal nerve stimulator device at issue in this case meets all 
Medicare criteria for medically reasonable and necessary and safe and effective for the enrollee. The provided 
records in this case document a sleep study dated October 7, 2023, showing an overall apnea hypopnea index 
of 88.7 events per hour. Medicare's Local Coverage Determination (LCD): Hypoglossal Nerve Stimulation for 
Obstructive Sleep Apnea (L38276) requires an apnea-hypopnea index (AHI) of 15 to 65 events per hour within 
24 months of initial consultation for device implant. Medicare LCD criteria for coverage are not met in this 
case.  
 
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 open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal 
respiratory sensor electrode or electrode array (64582), generator, neurostimulator (implantable), 
nonrechargeable (C1767) and patient programmer, neurostimulator (C1787).
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. At the time of the request for LTACH services, the enrollee is receiving pain medication, daily 
dressing changes and there are discussions regarding percutaneous endoscopic gastrostomy (PEG) placement. 
The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that 
are not available at the health care setting being offered by the Health Plan. The requested LTACH services are 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to 
be furnished safely and effectively only on an inpatient basis. 
 
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.