Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
the enrollee requires three medically justified actuators for their recommended power wheelchair. You also say 
that based on this, the enrollee will require E2377 and E2313. The Plan denied your request. The Plan says 
although there are three requested power options (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has adequate strength to 
manage standard power drives. Our reviewer also found that this request is not medically necessary to meet the 
enrollee's 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 an electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for avulsion of nail plate (11730) provided on August 24, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the billed code is not supported.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 11730 is avulsion of nail plate, partial or complete, 
simple; single. 
 
We asked our coder 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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The procedure report does not include documentation of avulsion of 
nail plate. Our coder was unable to cite the report, as this procedure was not found in the documentation submitted. 
 
We looked at this coder'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 pay for avulsion of nail plate (11730) provided on August 24, 2022.
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's current medical and physical condition 
require an IRF admission. 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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show that you have a complex 
rehabilitation need that would necessitate evaluation by a rehabilitation doctor 3 times per week. 
 
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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's records 
do not that you can tolerate 3 hours of therapies per day. Services needed may be provided safely in 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 the complexity of your nursing, medical and rehabilitation needs 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxilla osteotomy (21206), rhinoplasty (30410), 
suction assisted lipectomy (15876), and genioplasty (21121). 
 
You asked the Plan to pre-approve the osteotomy, rhinoplasty, lipectomy, and genioplasty. You say that you 
are requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
requested procedures are considered cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked at the case file and Medicare rules. The record shows the requested surgical procedures are 
considered cosmetic when performed as part of the surgical treatment for gender dysphoria. Therefore, we 
decided that the Plan does not have to pre-approve a maxilla osteotomy (21206), rhinoplasty (30410), suction 
assisted lipectomy (15876), and genioplasty (21121).
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 at a high risk for falling. The Plan 
denied your request. The Plan says the enrollee's records do not show that you have complex rehabilitation 
needs that require frequent evaluation by a rehabilitation doctor. 
 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
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 need for IMRT is not justified 
based upon quantifiable dosimetric measures or a plausible rationale for this enrollee. The American Society of 
Therapeutic Radiation and Oncology (ASTRO) model policy emphasizes the need to support IMRT with 
dosimetry; this would be of particular importance for clinical scenarios for which IMRT is not considered 
standard. The use of IMRT is not the standard of care and not medically necessary for this enrollee.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensity modulated radiation therapy (IMRT).
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 has had a severe decline in function 
following acute hospitalization and presently is continuing to decline as a direct result of this denial. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
Inpatient Rehabilitation Facility. 
 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the optometry services provided on November 28, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON optometry services. You say that no referral should be required for 
these services, and it is felt that the claims are being processed as OON in error. You state that you were told 
by a representative in credentialing that you are showing as in-network with the Plan. The Plan denied your 
request. The Plan says review of phone logs shows no documentation of a call to the Plan's credentialing 
department. The Plan's systems confirm that this provider is OON for the date of service at issue. This was a 
routine exam with no authorization requested and was denied correctly.   
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the optometry services provided on November 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-contrast CT of the heart with calcium scoring 
(75571). 
 
You asked the Plan to pre-approve non-contrast CT of the heart with calcium scoring. You say that 
uncontrolled hyperlipidemia is a serious genetic disease for you. The Plan denied your request. The Plan says 
preventive and screening services are not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 non-contrast CT of the heart with 
calcium scoring. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
absent demonstration of CMS requirements for such screening in an asymptomatic enrollee the exam should be 
denied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-contrast CT of the heart with calcium scoring have not been met. Therefore, we decided that the Plan does not have to pre-approve non-contrast CT of the heart with calcium 
scoring (75571).
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 IRF services requested are not medically reasonable or 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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide (S9122) provided from June 1, 2022, to 
December 31, 2022. 
 
You asked the Plan to pay for the home health aide. You say that the enrollee had a stroke while traveling in 
Taiwan in 2019 and she is currently still Taiwan recovering. You also say that you spoke with a Plan 
representative who advised that after the $100 deductible, the enrollee's home health aid would be covered at 
100%. The Plan denied your request. The Plan says a home health aid is not emergency services or urgently 
needed services for a stroke from 4 years ago. The Plan also says that the enrollee is not in a hospital or any 
emergency setting. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage. 
 
We looked at the file and Medicare rules. Specifically, the services provided were not for an emergency or 
urgently needed care. Based on this information, we decided that Medicare rules for coverage of the home 
health aide have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
aide (S9122) provided from June 1, 2022, to December 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided from December 8, 
2022, through December 11, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity.  
 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 services. Our reviewer found the medical 
documentation does not support 99233 as the medical decision making did not match 3 of 3 requirements 
needed to code the 99233. 
 
We looked at this physician reviewer'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 pay for subsequent hospital care (99233) provided from December 8, 2022, through December 
11, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 syringes of Evenity. 
 You asked the Plan to pre-approve Evenity. You say that your surgeon told you if you do not get this 
medication, you will collapse and end up in a wheelchair. You also say that you need this medication now. The 
Plan denied your request. The Plan says the information provided by your doctor did not meet the requirements 
for covering this drug. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that you do 
not meet the coverage criteria for Evenity. Our physician reviewer found the Plan requires a trial of Tymlos 
before they will approve the requested drug. In this case, you have not tried and failed the required drug. Our 
reviewer also found that there is no documentation provided indicating that the Plans required drug would 
likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve 2 syringes of Evenity.