Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the leadless pacemaker (Transcatheter insertion or 
replacement of permanent leadless pacemaker, right ventricular, including imaging guidance) (CPT Code 
33274). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not a covered benefit because your records show the enrollee will not be 
enrolled in a clinical study. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Leadless pacemakers are non-
covered when furnished outside of a CMS approved CED study. The records we received do not show that the 
patient is registered in an FDA approved study. Therefore, we decided that the Plan does not have to pre-
approve the leadless pacemaker (Transcatheter insertion or replacement of permanent leadless pacemaker, right 
ventricular, including imaging guidance) (CPT Code 33274).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. 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. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 additional occupational therapy visits. 
 
 
You asked the Plan to pre-approve 10 additional occupational therapy visits. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the enrollee is lacking in significant improvement. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 10 additional occupational therapy 
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the enrollee suffered a displaced fracture 
of medial malleolus of left tibia. The enrollee has received 30 units of occupational therapy. As of October 13, 
2020, the enrollee had progressed in bed mobility and participate in upper body activities of daily living, so that 
she was no longer dependent upon a caregiver for bed level care. Her prognosis for increased balance was 
excellent, with improved cognitive status, ability to focus, and participate in therapy. The requested therapy is 
generally accepted as specific and effective therapy for the patient's condition and can be safely and effectively 
performed only by or under the supervision of a therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional occupational therapy visits have been met. Therefore, we decided 
that the Plan has to pre-approve 10 additional occupational therapy visits. 

 
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: Favorable

 
We decided that the Plan has to pre-approve an inpatient hospital level of care. 
 
You asked the Plan to pre-approve an inpatient hospital level of care. You say that the requested inpatient 
hospital level of care is medically necessary. The Plan denied your request. The Plan says that the requested 
inpatient hospital level of care is not medically necessary. 
 
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 an inpatient hospital level of care. Our 
reviewer says that the requested inpatient hospital level of care is medically necessary. Our physician reviewer 
found the enrollee is with weakness, is non-ambulatory and presents with profound anemia and low iron 
consistent with iron deficient anemia. Given the enrollee's age, decline in functioning capacity, and evidence of 
probable blood loss that would be best diagnosed prior to discharge, is it reasonable and indicated that the 
enrollee would be thought to stay 2 or more midnights for evaluation. An inpatient level of care is medically 
reasonable 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 an inpatient hospital level of care have been met. Therefore, we decided that the 
Plan has to pre-approve an inpatient hospital level of care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for Pilates training provided from January 2, 2020, 
through May 7, 2020. 
 
You asked the Plan to reimburse you for the Pilates training. The Plan denied your request. The Plan says your 
Plan has a Fitness Program coverage through the Plan's fitness provider, which is a health and fitness program 
that provides monthly basic memberships. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits 
only when provided by the Plan's fitness provider. 
 
The Plan's rules for coverage of gym benefits have not been met because the provider at issue in this case is not 
a contracted Plan fitness provider. Therefore, we decided that the Plan does not have to reimburse you for 
Pilates training provided from January 2, 2020 through May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a backup knee ankle foot orthosis. 
 
You asked the Plan to pre-approve repairs to a backup knee ankle foot orthosis. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says you currently have a 
replacement knee ankle foot orthosis that is in good working order. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have received a replacement knee ankle foot orthosis. The replacement knee ankle foot 
orthosis serves the same purpose as repairs to a backup knee ankle foot orthosis. Therefore, we decided that the 
Plan does not have to pre-approve repairs to a backup knee ankle foot orthosis.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need these trips to be approved so you 
can get to your medical appointments. The Plan denied your request. The Plan says you have used up the 
maximum benefit for routine transportation for this year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotic inserts. 
 
You asked the Plan to pre-approve the foot orthotics. You say that you feel this should be covered whether or 
not you use a brace because your other foot was amputated and you have pain and swelling of the ball joint of 
your foot which this insert will help reduce. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotic inserts.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of the 
head/neck. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRA is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has complaints of 
headaches and chronic right foot pain and numbness felt to be secondary to reflex sympathetic dystrophy. It is 
noted in the medical record that the enrollee has diffuse headaches a couple times a week without associated 
symptoms which are much less severe with Fioricet. The records do not support medical necessity of the 
requested MRA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance angiography (MRA) of the head/neck.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is not safe in independent 
living. SNF care is appropriate for the enrollee so that she can have supervised care with medication 
administration oversight and nutritional support. The Plan denied your request. The Plan says the enrollee has 
not had a change in function that would require the need for daily skilled therapy. 
 
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. 
 
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 SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 79 year old 
female with a medical history that includes depression and dementia. From a nursing perspective, the 
beneficiary received oral medications. The beneficiary had stable vital signs. Regarding rehabilitation services, 
the beneficiary received PT and ST. The beneficiary was at a stand by assist level with functional mobility 
 
 
including gait to 450 feet with no assistive device. She was alert with confusion. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting.  
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Entresto.  
 
Benefits for these services 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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee's condition requires a higher level of care.The Plan denied your request. The Plan says the enrollee is medically stable and needs no frequent oversight from physicians nor intensive therapy services.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 fileand 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. Ourphysician reviewer found the enrollee is a 65 year old male with a past medical history of osteoarthritis, cirrhosis, heart failure, chronic obstructive pulmonary disease and hypertension who presented to the acute hospital on 10/25/2020 with upper gastrointestinal bleeding related to gastric ulcers. He was treated in the hospital and discharged to home with home health services on 11/05/2020. He is weak and unsteady and is working with physical and occupational therapy in the home. Based on the medical records provided, the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services, but the patient does not require an intensive inpatient rehabilitation therapy program. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior fusion (C3- C7) for the enrollee. 
 
You asked the Plan to pre-approve posterior fusion (C3- C7). You say that this procedure is medically 
necessary for the enrollee. The Plan denied your request. The Plan says this procedure was denied because the 
computed tomography (CT) scan has yet to be reviewed and the enrollee must be smoke free. 
 
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 posterior 
fusion (C3- C7). Our reviewer says that medical necessity has not been demonstrated in this case. Our 
physician reviewer found based on the documentation provided, the medical records do not show that there 
have been adequate conservative measures to include trial and failure of physical therapy. The medical records 
provided would indicate more conservative measures are needed. Medical necessity has not been established.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of posterior fusion C3- C7 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve posterior fusion (C3- C7) for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the ESI. You say that the enrollee was helped by the prior injection and 
further treatment would be beneficial. The Plan denied your request. The Plan says that the enrollee's pain was 
not sufficiently helped by prior ESI. As such, further treatment is not warranted. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs are covered to treat refractory pain caused by 
certain conditions defined above. Repeat treatments may be considered medically necessary if there was 
positive response to prior injections.  
 
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 ESI. Our reviewer says that the 
documentation supports the medical necessity of the requested ESI. Our physician reviewer found the enrollee 
has a history of multilevel spinal surgery and adjacent level disc disease. He had an Epidural Steroid Injection 
at the requested level and achieved 2 months of 60% pain relief. The request is for a repeat ESI. Since the 
enrollee received excellent pain relief from the first injection, a repeat ESI 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 ESI have been met. Therefore, we decided that the Plan has to pre-approve a 
repeat epidural steroid injection (ESI).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
 
 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft at the time of implant placement. 
 
You asked the Plan to pre-approve the bone graft. The Plan denied your request. The Plan says this service is 
not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
graft at the time of implant placement.
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 you can only get the care you need in an 
LTACH. The Plan denied your request. The Plan says your treatment can be continued in the current hospital. 
 
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 you appear to be unstable for transfer currently and require additional acute care 
services that can safely be performed at the current facility. You do not requires services at the LTACH that are 
not already available at the current 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.