Persius/hicric huggingface dataset:
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 denial of IRF services for the enrollee is 
unfounded and contradictory to the best outcome and appropriate care for the enrollee. The Plan denied your 
request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. 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 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 this 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Diclofenac Sodium. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 pre-approve Diclofenac Sodium.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve provider office visits to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve provider office visits. You say that the Plan has made a clerical error. The 
Plan denied your request. The Plan says rules for coverage for OON services have not been met. 
 
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 
provider office visits to be provided by an out-of-network (OON) provider.   
 
Your complaint about a persistent error in the Plans system regarding the network status of your desired 
provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 ready to transfer to an acute IRF. The 
Plan denied your request. The Plan says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can 
receive further services 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: 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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee continued stay at acute hospital until the enrollee is stable 
enough for discharge to a lower level of care has not been denied. 
 
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 enrollee was admitted with acute on chronic hypoxic respiratory failure 
secondary to pulmonary edema. The record indicates that the enrollee has ongoing medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer. 
 
You asked the Plan to pre-approve the Vertiflex interspinous spacer. You say that the Vertiflex interspinous 
spacer is medically necessary. The Plan denied your request. The Plan says the Vertiflex interspinous spacer 
is 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 Vertiflex interspinous spacer. Our 
reviewer says that the requested Vertiflex interspinous spacer is not considered medically reasonable and 
necessary. Our physician reviewer found that the Vertiflex interspinous spacer is experimental. 
 
 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 Vertiflex interspinous spacer have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Vertiflex interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Buzzaround Lite 3-wheel scooter (K0800). 
 
You asked the Plan to pre-approve a Buzzaround Lite 3-wheel scooter. You say that it is your professional 
medical opinion that the enrollee requires a motorized scooter to permit them to complete their activities of 
daily living (ADLs) and instrumental activities of daily living (IADLs) safely and efficiently. The Plan denied 
your request. The Plan says this request was denied because there was not any information about where 
primary use of the scooter would be, if the enrollee can propel themself in a wheelchair, or if an expert came to 
the enrollee's home to check the seating. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
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 Buzzaround Lite 3-wheel scooter. Our 
reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the 
enrollee has degenerative spine disease and ambulates with a cane. Physical exam reports normal gait and 
stance and normal strength and reflexes in their lower extremities. Our reviewer also found that the record does 
not support the enrollee requires a power mobility vehicle to manage self-care in the home. 
 
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 Buzzaround Lite 3-wheel scooter have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Buzzaround Lite 3-wheel scooter (K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PROLIA. 
 
You asked the Plan to pre-approve PROLIA. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 PROLIA. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has osteopenia demonstrated on 
DEXA scan. The review has determined that the documentation does not support that the Prolia is medically 
reasonable and necessary for the enrollee. The documentation does not support that the Prolia is safe and 
effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PROLIA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PROLIA.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a power wheelchair electronic connection. 
 
You asked the Plan to pre-approve the requested item. You say that the services are medically necessary. The 
Plan denied your request. The Plan says that the power options do not need to be controlled through a joystick.  
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical 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 the requested item. Our physician 
reviewer found that the enrollee has a medical history of spina bifida. Other medical history includes 
hypertension and anxiety. The enrollee is independent with daily activities, including toileting, dressing, and 
bathing/showering. He is noted to have a history of skin breakdown of the ischial tuberosity. Motor strength in 
the upper extremities was noted to be 3 out of 5, and 2 out of 5 in the lower extremities. The complexity of the 
enrollees seating and positioning needs necessitates a more complex group 3 power wheelchair base. The 
electronic connection is necessary to operate the group 3 power wheelchair base and the power options. 
Therefore, the electronic connection (E2311) is 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 the requested item have been met. Therefore, we decided that the Plan has to 
pre-approve a power wheelchair electronic connection.  
 
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: 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 you are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute inpatient 
rehabilitation setting have not been met.  
 
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 medical, rehabilitation and nursing needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. At the current 
functional level, the enrollee needs routine physical and occupational therapy and does not need intensive 
therapies consisting of at least three hours of therapy per day at least five days per week with a 
multidisciplinary approach in an IRF. The enrollee's rehabilitation needs can be safely provided in an alternate 
and low intensity setting such as continuing in a skilled nursing facility. The documentation does not support 
necessity for admission to 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that the enrollees condition is severe, and the injection is 
the required treatment. The Plan denied your request. The Plan says the enrollee does not meet the step therapy 
requirements for the requested drug to be approved. 
 
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 Eylea. Our reviewer says that the 
requested drug is not medically reasonable or necessary for approval at this time. Our physician reviewer found 
the Plan requires a trial of Byooviz before they will approve the requested drug. The documentation submitted 
does not show the enrollee has tried and failed the Plan's preferred drug. The available clinical documentation 
does not sufficiently support that the preferred drug would likely be less effective or have adverse effects for 
the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
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 meets criteria for acute inpatient 
rehabilitation. The Plan denied your request. The Plan says the request 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 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 
does not require treatment by multiple therapies, including either physical or occupational therapy, at an 
intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication 
that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours 
a week, under the supervision of a physician with at least three visits weekly to regain or maintain their 
functional status. The enrollee can receive further services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service May 30, 
2023. 
 
You asked the Plan to pay for procedure code 99213. You say that the enrollee was seen for multiple 
diagnoses. The Plan denied your request. The Plan says payment for code 99213 is bundled into payment for 
code 20611. 
 
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, we have confirmed that code 99213 is a column II code to column I code 20611. We find that code 
99213 was billed with the -25 modifier. The medical records show that the enrollee was seen for back pain, 
elbow pain, and knee pain. As part of treatment for the knee pain, the enrollee received an injection. The 
records do not show that the office visit, coded 99213, was a separate identifiable evaluation and management 
service. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99213 billed for date of service May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system-high frequency oscillation lung 
expansion device (E1399). 
 
You asked the Plan to pre-approve a lung expansion device. You say that you disagree with the denial and 
request reconsideration for a three-month rental of the Volara system. The Plan denied your request. The Plan 
says Medicare guidelines state that there is no data to support that this device using IPV is effective and 
additionally, is not covered for use in the home. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of a lung expansion device have not been met. Specifically, the provider is recommending this device 
for use in the home and the use of IPV in the home is not covered by Medicare or the Plan. Therefore, we 
decided that the Plan does not have to pre-approve a Volara system-high frequency oscillation lung expansion 
device (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facial feminization surgery. 
 
You asked the Plan to pre-approve facial feminization surgery. You say that facial feminization surgery is 
medically necessary. The Plan denied your request. The Plan says the requested facial feminization surgery is 
cosmetic and not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that corrective facial surgery will be considered 
cosmetic rather than reconstructive when there is no functional impairment present. Cosmetic surgery or 
expenses incurred in connection with such surgery, for the sole purpose of improving ones appearance, 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 facial feminization surgery. Our 
reviewer says that the requested facial feminization surgery is not considered medically reasonable and 
necessary. Our physician reviewer found that facial feminization surgery is considered cosmetic and thus not 
covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facial feminization surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facial feminization surgery.