Persius/hicric huggingface dataset:
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says LTACH care is not medically necessary. 
 
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 has diffuse stherosclerosis and was admitted to the current acute care 
hospital with a left foot osteomyelitis. He was treated with partial amputation surgery, IV antibiotics, and 
hyperbaric oxygen therapy. He is currently requiring basic wound care (plain gauze only), continued IV 
antibiotics (total of 6 weeks), and hyperbaric oxygen therapy. The enrollee does not require any services at the 
LTACH which are not already available in the current facility. There are no services at the LTACH which the 
patient requires that are not already available and covered at the current facility. The enrollee can continue 
antibiotics, HBO therapy, and basic wound care at the current facility and soon 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hydrogen breath testing. 
 
You asked the Plan to pre-approve the hydrogen breath testing. You say that you will be having major surgery 
in 3 weeks and won't be able to do the test. You say that your doctor thinks you have small bacterial 
overgrowth. The Plan denied your request. The Plan says the requested service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that breath tests are excluded from coverage when 
being used in diagnosing small bowel bacterial overgrowth. 
 
We looked at the file and Medicare rules. The records show that the test being requested is intended to 
diagnose small bowel bacterial overgrowth. Based on this information, we decided that Medicare rules for 
coverage of the hydrogen breath testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve hydrogen breath testing.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve homemaker services. 
 
You asked the Plan to pre-approve homemaker services. The Plan denied your request. The Plan says Medicare 
does not pay for custodial care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
The file shows that person care for showering was requested. We looked at the file, and Medicare rules. 
Custodial care, such as bathing and dressing, are not covered. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve homemaker services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair. 
 
You asked the Plan to pre-approve a recliner chair. You say that you cannot lay in bed all day due to 
circulatory and heart problems. The Plan denied your request. The Plan says a recliner chair is furniture, and is 
not used to care for a medical problem. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a recliner chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON services. You say that you have been seeing this provider for 
many years. The Plan denied your request. The Plan says there are no out-of-network benefits when services 
are available within the network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical 
services 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require intensive medical care, or aggressive therapy to regain function. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that the enrollee's current level of function is moderate assist for bed mobility and transfers. He is dependent for 
all activities of daily living. The enrollee is currently medically stable with no evidence of complex medical 
issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab 
nursing care. While she may benefit from continuing speech, physical, and occupational therapy, there is no 
evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician 
oversight and 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from 24-hour nursing care, 
regular physician visits, and intense therapy to build up strength. The Plan denied your request. The Plan says 
the enrollee's medical care does not require a rehab doctor three times per week, or aggressive therapies 3 hours 
per day. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that the enrollee is generally medically stable, with no recent neurological or orthopedic events. There is no 
evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per 
week, or a need for acute rehab nursing care. While he may benefit from continuing physical and occupational 
therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with 
frequent physician oversight and an interdisciplinary approach to rehabilitation care. Based on review of the 
available records, the enrollee does not meet criteria for coverage for an 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation or kyphoplasty. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation or kyphoplasty. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA is covered when specific criteria is 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 percutaneous vertebral augmentation or 
kyphoplasty. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
criteria is not met. There is no evidence of an acute compression fracture in the spine. The cause of back pain is 
not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation or kyphoplasty have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation or 
kyphoplasty.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hyalgan injection. 
 
You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says the enrollee has not 
had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc. 
 
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 Hyalgan. Our physician reviewer found 
that the enrollee has pain related to osteoarthritis of the right knee. He has failed conservative treatment. The 
Plan requires a trial of drug(s) Orthovisc and Monovisc before they will approve the requested drug. The 
enrollee has not tried and failed the required drugs. There is no indication that the plan's required drugs would 
likely be less effective, or likely have adverse effects 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Hyalgan injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Motegrity for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
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 Motegrity for the enrollee.  
 
Benefits for this drug 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a substance abuse residential treatment 
facility. 
 
You asked the Plan to pre-approve the requested services. You say that you will relapse if you are sent to sober 
living. The Plan denied your request. The Plan says residential treatment has not proven beneficial. 
 
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 requested services. Our physician 
reviewer found that you have not shown mood instability, thoughts of harming yourself or others. You do not 
have any delusions or hallucinations, or any auditory or visual hallucinations. Your drinking behavior has been 
conflicting based on the documentation presented. You were cooperative with care actively involved in your 
treatment. In cases such as this an evidence-based, objective, instrument such as the American Association of 
Community Psychiatrists Level of Care Utilization System is indispensable in determining necessary level of 
care for adults. In terms of Risk of Harm, the records support a score of 1 due to no current suicidal ideation or 
homicidal ideation. With regards to Functional Status, the records support a score of 1 due to some mild 
comorbidity. 
 In terms of Medical, Addictive and Psychiatric Comorbidity, the records support a score of 1 due to overall no 
comorbidity. In terms of level of stress of the Recovery Environment, the records support a score of 1 due to a 
low stressful environment. With regards to Level of Support for the recovery environment, the records support 
a score of 1 due to highly supportive environment and availability of treatment resources but also some 
difficulty in relationships with his family members. With regards to Treatment and Recovery History, the 
records support a score of 1 due significant response to treatment. In terms of Engagement and Recovery 
Status, the records support a score of 1 due to optimal to positive engagement for recovery. Thus, you have a 
composite score of 7. This correlates with treatment in a community-based outpatient treatment. All told, the 
requested residential treatment program services are not medically necessary for your treatment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a substance abuse residential treatment facility.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiogram (TTE) test. 
 
You asked the Plan to pre-approve TTE test. You say that you have an appointment scheduled for this test. The 
Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this 
routine re-evaluation is not considered medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that TTE testing may be covered for certain clinical 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve TTE test. Our reviewer says that you 
meet the Medicare criteria for the requested TTE test. Our physician reviewer found you have a history of 
right-sided heart failure. You have recent weight gain, edema, and increasing B-Type Natriuretic Peptide 
(BNP). The requested TTE 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 TTE test have been met. Therefore, we decided that the Plan has to pre-approve 
a transthoracic echocardiogram (TTE) test.   
 
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: Favorable

 
We decided that the Plan has to pre-approve a single photon emission computed tomography (SPECT/CT) 
scan, a special kind of combined picture done to show growths, inflammation, or movement of the injected 
agent in the body, of a single area of the body. 
 
You asked the Plan to pre-approve a SPECT/CT scan. You say that the services are necessary. The Plan denied 
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 a SPECT/CT scan. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found as the enrollee has had multiple injections without clinical success it is reasonable for the 
orthopedist to attempt to identify the source most likely to be causing the enrollee's symptoms. The use of 
SPECT CT is indicated in light of all the given history so that targeted therapy may be considered. 
 
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 SPECT/CT scan have been met. Therefore, we decided that the Plan has to 
pre-approve a single photon emission computed tomography (SPECT/CT) scan, a special kind of combined 
picture done to show growths, inflammation, or movement of the injected agent in the body, of a single area of 
the body.  
 
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 spinal surgery for the enrollee. 
 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is supported when the enrollee has had treatment that did not help. 
 
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 surgery. Our reviewer says that the 
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation of a trial and failure of adequate conservative measures, including recent 
physical therapy. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for Gamunex-C with an out-of-network 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the health plan requires that the requested services be obtained from participating/in-
network doctors, except in a few situations. 
 
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 
a referral for Gamunex-C with an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).

You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lumbar spine. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. She has mild left hip flexor weakness and left lower extremity parathesias. There is no mention in the records if the mild left hip flexor weakness is a new symptom or part of the 3-year chronic history. Her reflexes are normal. Absent any red flags to mandate immediate MRI there are no contraindications to a monitored 6-week trial of physical therapy. Note the enrollee has been instructed to return for a 3-month visit. Also, no plain film lumbar spine series is mentioned in the records.

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 MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ofev. 
 
You asked the Plan to pre-approve Ofev. You say that the enrollee is unstable with current treatment. The Plan 
denied your request. The Plan says the drug is not covered by the enrollee's medical 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 Ofev.