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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is still too weak and needs additional 
attention and therapy to regain strength. The Plan denied your request. The Plan says the enrollee's 
rehabiliation and medical needs can safely be met with part-time therapy and nursing services. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee is able to walk well above a basic community level and perform activities 
of daily living (ADLs) with only hands assist for balance cues. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the quarterly allowance for the over-the-counter (OTC) 
benefit be carried over to the next quarter. 
 
You asked the Plan to pre-approve quarterly allowance carry over. You say that you placed an order at the end 
of March. You say that you have not received it. You say that you really needed those items for personal 
reasons. You also say that you do not have an order number. The Plan denied your request. The Plan says the 
quarterly benefit for the over-the-counter benefit cannot be carried over to another quarter. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. The Evidence 
of Coverage clearly states that the over-the-counter quarterly allowance cannot be carried over to another 
quarter. The file also indicates there is no record of an order number or record of an order being placed. 
Therefore, we decided that the Plan does not have to pre-approve the quarterly allowance for the over-the-
counter (OTC) benefit be carried over to the next quarter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. 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 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 Opdivo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found subsequent immunotherapy is not 
recommended with progression on a prior immunotherapy per the NCCN Guidelines. The use of Nivolumab 
(Opdivo) is not reasonable or medically necessary and unlikely to be safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS heart failure system (33289, C2624). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that you believe that the CardioMEMS 
implant is medically reasonable and necessary and as such this service should receive prior authorization of 
coverage and payment. The Plan denied your request. The Plan says this device is considered experimental and 
investigational as there are not enough studies to show the CardioMEMS device will help in the enrollee's care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare only covers the CardioMEMS device when it is used in a 
Medicare approved clinical research study. The records do not show the enrollee will be or is enrolled in a 
Medicare approved clinical research study. Based on this information, we decided that Medicare rules for 
coverage of the CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the CardioMEMS heart failure system (33289, C2624).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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. The enrollee's 
medical status does not currently require intensive rehabilitation physician or nursing oversight in an IRF. The 
enrollee's functional level does not require treatment by multiple therapies including physical or occupational 
therapy only in an intensive rehabilitation program in an IRF. While the enrollee may be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF the 
documentation does not reveal that this is medically necessary. The enrollee's needs can be safely and 
effectively met 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.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve alveoloplasty not in conjunction with extractions - four or more 
teeth or tooth spaces, per quadrant (D7320) and intravenous moderate (conscious) sedation/analgesia- first 15-
minutes (D9239). 
 
You asked the Plan to pre-approve dental services. You say that you believe the services should be covered. 
The Plan denied your request. The Plan says that these services are not covered under your Plan. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We sent a request for the 2023 Evidence of Coverage (EOC) but the Plan did not 
send it to us. We are unable to verify what the current dental coverages are without the appropriate Plan 
documentation. Therefore, we decided that the Plan has to pre-approve alveoloplasty not in conjunction with 
extractions - four or more teeth or tooth spaces, per quadrant (D7320) and intravenous moderate (conscious) 
sedation/analgesia- first 15-minutes (D9239).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) (77373, 
77470, 77370). 
 
You asked the Plan to pre-approve SBRT. You say that treatment is medically necessary. The Plan denied your 
request. The Plan says the request does not meet the Medicare or health plan coverage criteria. The treatment 
offers no recognized chance of oncological success coupled with a recognized/ known chance of toxicity/harm. 
SBRT can no longer be considered standard of care for most individuals with oligometastatic breast cancer. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for the enrollee; the plan is to treat a liver metastasis; reportedly the other sites of metastases 
are well-controlled. It is unclear the extent of the widespread disease (that is reportedly controlled). Among 
those with breast cancer, 47 enrollees were randomized to receive SBRT to all oligoprogressive lesions or 
standard of care treatment. There was no significant benefit with respect to progression free survival with the 
addition of SBRT with the authors concluding, No benefit of SBRT seen in the breast cohort. Most breast 
enrollees developed new lesions upon further progression. The most recent NCCN guidelines for breast cancer 
do not address oligoprogression as they do for NSCLC. The decision is unfavorable as SBRT for 
oligoprogression from breast cancer is not a standard of care treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT) (77373, 77470, 77370).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 15, 2022, 
through November 18, 2022.  
You asked the Plan to pay for inpatient hospital services.. You say that the enrollee requires hospital care. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 15, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient hospital 
services provided on November 15, 2022, through November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 lower limb prosthetic foot (L5986, L5987). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request exceeds the enrollee's need and cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a level 3 foot consisting of L5986 and L5987 is not medically necessary and exceeds the patient's functional needs. The enrollee uses a cane and walker which is not consistent with a K3 level of ambulation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a K3 lower limb prosthetic foot (L5986, L5987).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that your leg has been swollen for over three weeks 
and you are in a lot of pain. You have had surgery done by the requested provider in the past and you would 
like to see him again because he knows how to deal with your ongoing health issue. The Plan denied your 
request. The Plan says you must use in-network providers to receive services/care. This service is available by 
a provider in your network. 
 
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 
an office visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc injection. 
 
You asked the Plan to pre-approve a Synvisc injection. You say that the enrollee has an extremely long history 
of osteoarthritis of the knees. You say that you have done multiple conservative treatments with the enrollee 
over the years. The Plan denied your request. The Plan says documented imaging is needed.  
The Plan follows Medicare rules. Medicare rules say that viscosupplementation for intra-articular injections of 
the knee are covered when reasonable and necessary for specific clinical indications.  
 
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 Synvisc injection. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found there is no documentation of 
radiographic evidence of OA of the knee. The review has determined that the requested treatment is not 
indicated for the enrollee's condition. 
 
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 Synvisc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Synvisc injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care (procedure code 99226) 
rendered on August 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99226 (1 Unit) remains 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 99226 is "Subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
does not support the CPT code 99226. The enrollee was medically stable and responded appropriately to 
treatment. There is no indication that medical decision making of high complexity was needed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent observation care (procedure code 99226) rendered on August 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says a 
LDCT is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter. 
 
We reviewed the file and the Medicare rules. We find that the enrollee does not fall within the age range. 
Therefore, we decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a maxillary partial denture and mandibular partial denture. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that your benefit for the requested item or service has already been 
exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a maxillary partial denture and mandibular 
partial denture.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics  provided on February 1, 2022. You say that you would like 
reconsideration because the requested foot orthotics are medically necessary. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional injection level (procedure code 64495) 
rendered on September 28, 2022. 
 
You asked the Plan to pay for the additional services. You say that this should be paid for. The Plan denied 
your request. The Plan says the provider did not send in evidence of a unique circumstance to indicate a 
third/fourth level of injection. 
 
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 pay for the additional services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of the necessity to a third level of this injection. This request 
exceeds the utilization criteria of the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional services have not been met. Therefore, we decided that the Plan 
does not have to pay for an additional injection level (procedure code 64495) rendered on September 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from October 8, 2022, 
through October 10, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you are not sure what self-administered 
drugs were given to you during your stay. The Plan denied your request. The Plan says self-administered drugs 
do not fall under Medicare Part B coverage. 
 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 pay for self-administered drugs provided 
from October 8, 2022, through October 10, 2022.