Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve ablation of malignant prostate tissue, transrectal, with high 
intensity-focused ultrasound (HIFU), including ultrasound guidance (55880). 
 
You asked the Plan to pre-approve the HIFU procedure. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that there is no documentation that the enrollee has had 
prostate cancer in the past and this is a reoccurrence, or that the enrollee has had radiation therapy to the 
enrollee's prostate for prostate cancer in the past. 
 
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 the HIFU procedure. Our reviewer says 
that the requested HIFU is considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure was FDA approved for prostate gland ablation October 9, 2015. The reviewer found that 
there are more than 100 clinical studies, some with over 15 years of follow-up, that have demonstrated 
treatment efficacy that is comparable to surgery or radiation but with a much lower risk of side effects such as 
impotence, urinary incontinence, and bowel injury. Therefore, the reviewer found that the requested HIFU is 
medically reasonable and 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 HIFU procedure have been met. Therefore, we decided that the Plan has to 
pre-approve ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), 
including ultrasound guidance (55880).  
 
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 an office visit with an endocrinologist to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you are in pain and need this appointment The 
Plan denied your request. The Plan says their original decision to deny coverage was correct. 
 
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 with an endocrinologist to be provided by an out-of-network (OON) provider.
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 services are medically necessary for 
the enrollee's medical needs. The Plan denied your request. The Plan says the enrollee is receiving the 
appropriate care and is unstable for transfer to an LTACH. 
 
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 the provided records do not explain what care services will be provided in the 
LTACH that are not available in the present hospital setting. The enrollee is presently receiving appropriate 
services in the acute care setting. Records do not support the need to transfer from the current facility to 
another. Continued care in the acute care hospital is appropriate until the enrollee is stable to transfer to a lower 
level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 
facility. 
 
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.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One. You asked the Plan to pre-approve 
Synvisc One. You say that the enrollee has been seen and failed treatments. You would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says Synvisc One is subject to Step Therapy. There must be a trial and failure of one of the following medications before other medicines can be 
approved: Hyalgan, Euflexxa, Supartz, Gel-One.  
 
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 Synvisc One. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found there is no trial and failure of first line 
medications such as Hyagan or Supartz. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay at the psychiatric inpatient 
hospitalization level of care. 
 
You asked the Plan to pre-approve the inpatient level of care. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records do not show that you have ongoing 
dangerous behaviors or that you are receiving active medication treatment. 
 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 inpatient level of care. Our reviewer 
says that the requested continued stay for psychiatric inpatient level of care is not medically necessary. Our 
physician reviewer found the records provided do not indicate the enrollee appeared to require inpatient mental 
health treatment beyond the date in question as they were not a danger to themselves or others and does not 
have auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date 
in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or 
for the purpose of diagnosis beyond the date in question. Therefore, the reviewer found that the requested 
inpatient level of care 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 inpatient level of care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continued stay at the psychiatric inpatient hospitalization level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee cannot be adequately 
supported on a BiPAP device. You say that while those devices can provide a similar mode called AVAPS, 
they are not equipped with the same pressure and flow ranges or features necessary for patients needing 
advanced ventilation. The Plan denied your request. The Plan says a home ventilator is not medically necessary 
for this patient because their needs can be met with an alternative device such as a BiPAP device with average 
volume-assured pressure support (AVAPS).  
 
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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease. While the enrollee 
could be treated with a BIPAP machine with AVAPS capability, and failure of such a device has not been 
documented. Also, the documentation does not contain sufficient information in the medical records to justify 
the treatment selected and the plan has indicated coverage for such a device is available upon request. 
Therefore, the elements of the coverage criteria are not satisfied, and the requested service cannot be 
recommended. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient level of care for the laser enucleation of the 
prostate with morcellation (52649). 
 
You asked the Plan to pre-approve the acute inpatient level of care. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient level of care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this 
case. Our physician reviewer found this procedure is not listed as an inpatient only procedure and is typically 
performed in ambulator centers. The reviewer found that the provided documentation did not reveal the patient 
with an unstable condition or high-risk factors that would warrant inpatient care following the procedure. It is 
not expected that the patient would likely require hospital care that would likely cross 2 midnights or that the 
patient would likely have an adverse event. Therefore, the reviewer found that the request for the inpatient level 
of care 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 acute inpatient level of care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient level of care for the laser enucleation of the prostate with 
morcellation (52649).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve the injections. You say that you are in pain and need to have these injections 
so that you can have a better lifestyle. The Plan denied your request. The Plan says epidural steroid injections 
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 the injections. Our reviewer says that 
epidural steroid injections are not medically necessary. Our physician reviewer found that the request exceeds 
the utilization criteria. Therefore, the request is not medically reasonable and 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring Active Compression Garment 
System. 
 
You asked the Plan to pre-approve the Koya Dayspring Active Compression Garment System. You say that the 
items are medically necessary. The Plan denied your request. The Plan says this device is considered 
experimental. 
 
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 Koya Dayspring Active 
Compression Garment System. Our reviewer says that the requested items are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this specific device does not have 
sufficient high-quality literature to show it leads to long-term benefit superior to other standard methods available to help support this request. There were no exceptional circumstances shown in the provided 
documentation. 
 
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 Koya Dayspring Active Compression Garment System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Koya Dayspring Active Compression 
Garment System.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
currently does have the degree of medical complexity to require rehabilitation physician oversight. The enrollee 
does not require rehabilitation nursing for complex wound care. The enrollee's medical and rehabilitation needs 
do not require the intensive interdisciplinary approach provided on acute inpatient rehabilitation. The enrollee 
does not require treatment by multiple therapies. Therefore, the acute inpatient rehabilitation admission is not 
medically 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 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: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that 
there is no diagnosis of thoracic restrictive disease or neuromuscular disease. An arterial blood gas was 
consistent with acute on chronic hypercarbic respiratory failure. The enrollee may benefit from BiPAP with 
volume assurance during sleep. Medicare does not cover a home ventilator when used at settings that could 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and supplies. You asked the Plan to pre-approve a CGM and supplies. You say that you need the CGM system because you 
have to do finger sticks several times a day and your fingers swell up. The Plan denied your request. The Plan 
says the request is not medically necessary. 
 
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 use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a CGM and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with out-of-network (OON) 
ophthalmologist. 
 
You asked the Plan to pre-approve an OON consultation. You say that the enrollee was referred to another 
specialist. You also say that they cannot provide the level of care that the requested provider can. The Plan 
denied your request. The Plan says the requested service can be provided in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 OON consultation. Our reviewer 
says that the requested OON consultation is not medically necessary. Our physician reviewer found the Plan's 
denial is medically justified as the enrollee's medical condition can be referred to the in-network 
Ophthalmologist. The reviewer found that there are no unique circumstances, such as acute vision conditions or 
risk of vision loss, that would make it medically necessary to see the requested out-of-network provider. 
Therefore, the reviewer found that the requested consultation with an OON provider 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 an OON consultation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a consultation with out-of-network (OON) ophthalmologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve OON services. You say that the device will meet the enrollee's needs. The 
Plan denied your request. The Plan says the device is available by a network provider. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve durable 
medical equipment to be provided by an out-of-network (OON) provider.