Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 3 additional fractions of image guided radiation therapy (IGRT) 
services.  
 
You asked the Plan to pre-approve 3 additional fractions of IGRT services. You say that if you stop treatment 
at 21 fractions, this could cause the cancer to return. You say that 24 fractions of IGRT is medically necessary.  
The Plan denied your request. The Plan says that 24 instead of 21 fractions of IGRT is not reasonable and 
necessary for the enrollee's condition. 
 
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 3 additional fractions of IGRT services. 
Our reviewer says that the requested services are considered medically reasonable and necessary in this case. 
Our physician reviewer found guidelines say that the whole breast should receive a hypofractionated dose of 
4042.5 Gy in 1516 fractions; in selected cases 4550.4 Gy in 2528 fractions may be considered. Typical 
boost doses are 1016 Gy in 48 fractions. The issue in this case is the boost dose of 8 vs 5 fractions. While the 
3 additional fractions could have been planned differently (for example, planned with slightly higher dose per 
fraction and deliver 3 less fractions), the 8 fractions fall within guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 additional fractions of IGRT services have been met. Therefore, we decided 
that the Plan has to pre-approve 3 additional fractions of image guided radiation therapy (IGRT) services.   
 
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 insertion of a subcutaneous cardiac rhythm monitor 
(implantable loop recorder [ILR]). 
 
You asked the Plan to pre-approve the ILR device. You say that this is necessary to monitor the enrollee's atrial 
fibrillation and premature atrial contractions (PACs). You also say that this will prevent further complications 
for the enrollee. The Plan denied your request. The Plan says the documentation does not show that the enrollee 
has had a cryptogenic stroke. The Plan says the enrollee has not had any noninvasive cardiac monitoring, and 
the test results will not impact the enrollee's management. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an ILR device. Therefore, the reviewer found that the requested ILR device is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a subcutaneous cardiac rhythm monitor (implantable loop recorder [ILR]).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx for Prostate Cancer for date of service 
February 17, 2023. 
 
You asked the Plan to pay for ConfirmMDx for Prostate Cancer. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services rendered are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that [insert custom text from glossary].***} 
 
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 ConfirmMDx for Prostate Cancer. Our 
reviewer says that the documentation does not support that the testing rendered was medically reasonable or 
necessary. Our physician reviewer found the enrollee had a prostate biopsy showing T1c malignant disease 
who had molecular testing done. Molecular testing was not medically appropriate and does not meet the criteria 
outlined. The enrollee had known T1c prostate cancer on biopsy. Therefore, the enrollee did not meet criteria 
for the services rendered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ConfirmMDx for Prostate Cancer have not been met. Therefore, we decided 
that the Plan does not have to pay for ConfirmMDx for Prostate Cancer for date of service February 17, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot go to the bathroom and need assistance 
with daily activities. The Plan denied your request. The Plan says that you do not meet the requirements for 
inpatient rehabilitation. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found therapy evaluations show that you have good participation in therapy evaluations and an intensive 
rehabilitation regimen is recommended, criteria 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 pre-approve a computed tomographic angiography (CTA) of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve the CTA. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
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 the CTA. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee has a pelvic kidney meaning 
endovascular repair is not possible. While no symptoms have occurred, the increase in size of the abdominal 
aortic aneurysm (AAA) from 3.9 to 4.9 cm is cause for concern and surveillance every 6 months instead of 
yearly is reasonable. Request for surveillance CTA of the aorta should be approved at the 6-month interval as 
requested. 
 
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 CTA have been met. Therefore, we decided that the Plan has to pre-approve 
a computed tomographic angiography (CTA) of the abdomen and pelvis.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) virtual colonography 
(74261). 
 
You asked the Plan to pre-approve a CT virtual colonography. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is 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 a CT virtual colonography. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found CT colonography is not indicated. A colonoscopy with monitored cardiac 
anesthesia care is more 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 a CT virtual colonography have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) virtual colonography (74261).
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 requires an IRF admission to return to 
prior level of function. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary at this time. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with single power option and 
accessories (E2620, K0856, E0955, E1002, E1028, E2208, E2361, E2603). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with single power option and accessories. 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 follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
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 group 3 power wheelchair with single 
power option and accessories. Our reviewer says that the services are medically necessary. Our physician 
reviewer found based on the medical records provided there is documentation that the group 3 power 
wheelchair with single power option, power tilt and accessories at issue in this case meets all Medicare criteria 
for medically reasonable and necessary for the enrollee. There is documentation that this enrollee has a 
personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, 
feeding, grooming and bathing in customary locations within the home. There is documentation that the 
enrollee's mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. The enrollee can 
safely operate a power mobility device. Provided records from the patient's treating practitioner and the 
therapist performing the wheelchair evaluation report that the enrollee is high risk for skin breakdown and a 
cushion is not adequate for her needs. She is documented to be unable to transfer independently and she cannot 
perform a functional weight shift. Thus, she meets criteria for the power tilt and thus the single power option 
group 3 power wheelchair base. 
 
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 group 3 power wheelchair with single power option and accessories have been met. Therefore, we decided that the Plan has to pre-approve a group 3 power wheelchair with single power 
option and accessories (E2620, K0856, E0955, E1002, E1028, E2208, E2361, E2603).  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan provided on February 4, 
2023. 
 You asked the Plan to pay for the CT scan. You say that the claim was filed timely and should be processed. 
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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a computed tomography (CT) scan provided on February 4, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on January 3, 2023. 
 
You asked the Plan to pay for the telehealth services. You say that per the medical records, these service are 
covered under the patient's benefit plan and are necessary for the patient. The Plan denied your request. The 
Plan says virtual care out-of-network is not covered. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network.  
 
We looked at the file and the Plans rules. The file shows that virtual care (also referred to as telehealth 
services, virtual check-ins or eVisits) is not covered out-of-network. Based on this information, we decided that 
the Plans rules for coverage of the telehealth services have not been met. Therefore, we decided that the Plan 
does not have to pay for telehealth services provided on January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the hard material support for cap (D2950) on tooth #7. We decided 
that the Plan does not have to pre-approve the surgery to place a metal post in the jaw (D6010) on tooth #9, and 
the canal preparation and fitting of preformed dowel or post (D3950).  
 
You asked the Plan to pre-approve the hard material support for cap (D2950) on tooth #7, the surgery to place a 
metal post in the jaw (D6010) on tooth #9, and the canal preparation and fitting of preformed dowel or post 
(D2950). You say that the dental records support the medical necessity for the implants. The Plan says that the 
benefits have been exhausted for D2950 and D6010. The Plan says the D3950 is not a covered benefit. 
 
We decided that the Plan has to pre-approve the hard material support for cap (D2950) on tooth #7.  
 
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. The Plan has incorrectly applied this benefit. Therefore, we decided that the Plan has to pre-approve 
the hard material support for cap (D950) on tooth #7.  
 
We also decided that the Plan does not have to pre-approve the surgery to place a metal post in the jaw 
(D6010) on tooth #9, and the canal preparation and fitting of preformed dowel or post (D3950). 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted when the Plan approved D6010 on tooth #s 
8 and 10. Therefore, we decided that the Plan does not have to pre-approve D6010 on tooth #9. Though the 
Plan offers a dental benefit in excess of Medicare coverage, the canal preparation and fitting of preformed 
dowel or post (D3950) is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve the canal preparation and fitting of preformed dowel or post (D3950). 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lenses (V2100) and deluxe frames (V2025) provided on 
April 10, 2023.  
You asked the Plan to pay for lenses (V2100) and deluxe frames (V2025). You say that you have seen this 
provider for the last 10 to 15 years. You also say that the provider never mentioned any change in insurance. 
The Plan denied your request. The Plan says is not a participating provider in the Plan network and is not 
uniquely qualified to treat your condition. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received from providers in the Plan vision provider 
network. 
 
We looked at the file and the Plan's rules. The Plan rules also say that members must receive services from 
providers in the Plan vision provider network. Based on this information, we decided that the Plan's rules for 
coverage of lenses (V2100) and deluxe frames (V2025) have not been met. Therefore, we decided that the Plan 
does not have to pay for lenses (V2100) and deluxe frames (V2025) provided on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 03, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the provider was not responsible 
for obtaining authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on February 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve the Freestyle Libre 3. The Plan denied your request. The Plan says based on 
a review of the information available, no clinical rationale was received as to why the preferred product, 
FreeStyle Libre 2, is not clinically appropriate for the member. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Freestyle Libre 3 have been met. 
There were no medical records provided. Without the medical records we are unable to determine if the criteria 
for the FreeStyle Libre 3 have been met. The Plan has shown that they made reasonable attempts to obtain this 
necessary information. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 3.