Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from June 16, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from June 16, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
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 inpatient psychiatric care from June 16, 
2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of June 16, 2023, forward. Our physician reviewer found 
the enrollee did not require inpatient mental health treatment beyond June 16, 2023, as she was not a danger to 
herself or others and did not have any delusions, 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 for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from June 16, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from June 16, 2023, 
forward.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. You say that your mobility is limited because of knee pain and 
your knee buckling on you. You also say that these injections will help with your pain until you can have the 
surgery. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy 
criteria for the requested viscosupplement device. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Orthovisc or Supartz FX before they will approve the requested drug. In this case, you have not tried and failed 
the required drugs. Our reviewer also found that there is no documentation provided indicating that the Plans 
required drugs 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
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 services are medically necessary for the 
enrollee's care. The Plan denied your request. The Plan says an intensive rehabilitation program 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. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. The Plan denied your request. The Plan says you do not require 
close supervision by a physician. 
 
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: 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 you feel this machine would be the best fix 
for the enrollee's health. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in intelligent volume-assured pressure support (iVAPS) mode with auto-expiratory positive 
airway pressure that could be delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
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. 
 
 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 for the enrollee. Our physician reviewer found 
the record indicates that the enrollee has chronic respiratory failure from COPD and sleep apnea. The record 
indicates that the enrollee is being treated with BiPAP with improvement. Our reviewer found that the provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured 
pressure support (AVAPS) capability and failure of such a device has not been documented. Our physician 
reviewer found that the plan has indicated coverage for such a device is available upon request. The elements 
of the coverage criteria are not satisfied. Our reviewer also found that 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 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 home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the doctor has prescribed a ventilator to help the enrollee's breathing at 
various times of the day (night and day) because of lung disease. 
 
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. 
 
 
 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 the service is not medically necessary. Our physician reviewer found the enrollee has COPD, pulmonary 
hypertension, HFpEF, and coronary artery disease. The enrollee was prescribed a home ventilator in April 
2022, following hospitalization for exacerbation of heart failure and COPD. There are no pulmonary function 
tests to document airways obstruction and assess severity. Compliance reports from October 2022 to May 
2023, showed that the enrollee is not using the device enough to be effective. For the most recent month, the 
device was used for at least 4 hours/day on only 14% of days. If compliance could be achieved, this enrollee 
would likely benefit from BiPAP with AVAPS during sleep. There is no evidence that this has been tried and 
failed.  Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a 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 group 2 standard power wheelchair (K0842) and 
additional items and accessories (codes E1012, E1007, E2311, and E2359). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
You say that without having the approval of the power wheelchair it can cause health concerns, and the 
enrollee's mobility is limited by not having the wheelchair upon discharged from the inpatient facility. The Plan 
denied your request. The Plan says this request is not medically necessary because the records did not include a 
home assessment to ensure that the wheelchair is suitable for use in the enrollee's home as required by the 
Medicare Guidelines. The Plan also says that since the wheelchair is not medically necessary, the accessories 
for the wheelchair are unable to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that prior to or at the time of delivery of a POV or 
PWC, the supplier or practitioner must perform an on-site evaluation of the beneficiarys home, and there must 
be a written report of this evaluation available on request.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 standard power wheelchair and additional items and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power wheelchair 
(K0842) and additional items and accessories (codes E1012, E1007, E2311, and E2359).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle with a 
patient weight capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve a group 1 heavy duty power operated vehicle. You say that the enrollee has 
multiple medical problems which contribute to their inability to ambulate in their home. You also say that a 
motorized scooter will help with the enrollee's mobility at home and will make the enrollee more independent. 
The Plan denied your request. The Plan says this request does not meet the Medicare or health plan coverage 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 
95% of the weight capacity of the next lower weight class PWC. 
 
 
 Specifically, the provided records show that your most recent documented weight is below the required weight 
limit of 301 to 450 pounds for a group 1 heavy duty power operated vehicle (K0801). Therefore, we decided 
that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle with a patient weight 
capacity 301 to 450 pounds (K0801).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory specimen testing provided on October 28, 2022. 
 
You asked the Plan to pay for laboratory specimen testing. You say that this was medically necessary and 
should be covered. 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 laboratory specimen 
testing provided on October 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission to the IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an 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 the enrollee was independent prior to this 
hospitalization and will need intensive therapy to get back to their maximum level of functioning. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
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. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 the enrollee is need of physical and occupational 
therapy. The Plan denied your request. The Plan says the enrolleer 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 increase the reimbursement for the massage therapy sessions 
provided from March 10, 2022, to December 29, 2022. 
 
You asked the Plan to increase the reimbursement for the massage therapy sessions. You say that you should 
have been reimbursed the full billed amount minus the coinsurance. The Plan denied your request. The Plan 
says you were reimbursed the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 35% 
coinsurance for out-of-network physical therapy.  
 
The records show you have been reimbursed the allowed amount for each service minus the 35% coinsurance 
amount. This item/service falls within the outpatient rehabilitation services benefit category. This means that you have been reimbursed the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to increase the reimbursement for the massage therapy sessions provided from March 10, 2022, 
to December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that you have prostate cancer, and need this procedure to 
get well. The Plan denied your request. The Plan says the PBRT requested does not meet the requirements for 
approval. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than intensity modulated radiotherapy (IMRT)/image guided radiotherapy (IGRT). The generally 
accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not 
routinely offer it to patients. Our reviewer also found that while National Comprehensive Cancer Network 
(NCCN) guidelines consider proton therapy a reasonable alternative they do not describe it as being 
necessary in lieu of non-proton based treatment and are quite explicit in that there is no evidence of its 
superiority.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).