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

We decided that the Plan does not have to pre-approve 10 additional outpatient physical therapy visits.
You asked the Plan to pre-approve the 10 additional outpatient physical therapy visits. You say that the number
of visits being requested is medically necessary. The Plan denied your request. The Plan says the number of
visits being requested is not medically necessary. The Plan says that the enrollee should be able to transition
successfully to a home education program with the total number of approved visits.
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 the 10 additional outpatient physical
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 requested additional therapy
is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had
extensive therapy for this condition and it does not appear that the enrollee requires the ongoing unique skills
of a professional therapist to safely and effectively provide treatment, or that the services can be safely and
effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has been
authorized additional sessions to review an independent exercise program.
The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design
and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 10 additional outpatient physical therapy visits have not been met.
Therefore, we decided that the Plan does not have to pre-approve 10 additional outpatient physical therapy
visits
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the 
enrollee's clinical condition does not require skilled nursing 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. 
 
Continued services beyond January 15, 2021 were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, the 
enrollee had stable vital signs, his lungs were clear, and he was treated for pain with effect. There are no 
identifiable skilled nursing service needs. Regarding rehab services, he was at a minimal to maximal assist 
level with functional mobility. He required varying assist with activities of daily living. There are no 
identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a 
daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 
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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your feet are in constant pain and you are unable 
to wear regular shoes. 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 orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual physical exam (99397) provided August 25, 2020. 
 
You asked the Plan to pay for the annual physical. You say that you were told your doctor was no longer in-
network so you had to get a physical from a different doctor. The Plan denied your request. The Plan says only 
one annual physical exam is covered per year. 
 
The Plan must follow Medicare rules. Medicare rules say that an annual wellness exam is covered once every 
12 months. 
 
We looked at the file and Medicare rules. An annual physical was previously provided on May 19, 2020. Based 
on this information, we decided that Medicare rules for coverage of the annual physical have not been met. 
Therefore, we decided that the Plan does not have to pay for an annual physical exam (99397) provided August 
25, 2020.
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 records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care 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 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 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 is 
living at home experiencing falls and weakness. The enrollee's medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. 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 documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan. 
 
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 Lumigan.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you tested positive for COVID-19 and now 
require therapy assistance to improve your activities of daily living in order to get back to your prior level of 
function. The Plan denied your request. The Plan says the enrollee's needs can be met in a lower level of 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. 
 
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 services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and had stable vital signs. The enrollee was at contact guard/moderate to contact guard assist to 
dependent level of functional mobility. The enrollee required varying assist with activities of daily living. 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but 
they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service 
criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Blueprint genetic testing services. 
 
You asked the Plan to pre-approve the Blueprint genetic testing services. You say that the medical records 
provided support the need for the genetic testing services which remain in dispute. The Plan denied your 
request. The Plan says Blueprint genetic testing assay 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. Medicare rules say that there is insufficient evidence to support the required clinical 
utility for the Blueprint test, which is statutorily excluded from coverage. Therefore, we decided that the Plan 
does not have to pre-approve Blueprint genetic testing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the CardioMEMS system is 
indicated for wirelessly measuring and monitoring pulmonary artery pressure and heart rate in NYHA Class III 
heart failure patients who have been hospitalized for heart failure in the previous year. You say that the 
hemodynamic data are used by physicians for heart failure management and with the goal of reducing heart 
failure hospitalizations. The Plan denied your request. The Plan says the documentation provided does not 
support the need for the item in dispute because it is considered to be experimental and investigational. 
 
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 CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found therapy change based on data obtained from a CardioMEMS device has been 
demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to 
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare 
coverage criteria are not met since the device is considered experimental and investigational. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
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 covered. 
 
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.  Therefore, we 
decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cisplatin, Gemcitabine, Dexamethasone Sodium 
Phosphate, Fosaprepitant, and Palonosetron. 
 
You asked the Plan to pre-approve Cisplatin, Gemcitabine, Dexamethasone Sodium Phosphate, Fosaprepitant, 
and Palonosetron. You say that these services are medically necessary. The Plan denied your request. The Plan 
says the claim payment for a clinical trial is the responsibility of the original Medicare contractor. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
 
 
 
 
 
 
 
 
 
 
In this case, you asked the Plan to pre-approve Cisplatin, Gemcitabine, Dexamethasone Sodium Phosphate, 
Fosaprepitant, and Palonosetron as part of a clinical trial. The Plan does not cover routine costs associated with 
qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Cisplatin, 
Gemcitabine, Dexamethasone Sodium Phosphate, Fosaprepitant, and Palonosetron.
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 medical records provided support the 
need for care in an LTACH. The Plan denied your request. The Plan says LTACH care is not medically 
necessary. The Plan says that there are no required medical services in the LTACH that are not available at the 
approved hospital where the enrollee currently is. 
 
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 appears to be improving with treatment and only requires a short course 
of acute care services which can be safely completed in the current facility. The enrollee does not require 
services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. The enrollee's needs 
are not complex enough to warrant prolonged acute care services. Transfer to a lower level of care may be 
considered when treatment has completed. 
 
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: 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 need rehabilitation to regain his strength, 
work, improve his mobility, and for speech treatment. You say that the enrollee requires focused and intense 
treatment and therapy so that he can be discharged to home safely. You say that all of the enrollee's providers 
are recommending IRF care. The Plan denied your request. The Plan says the requirements for coverage of IRF 
care have not been met. The Plan says that the enrollee's current medical and rehabilitation needs are not of the 
intensity and complexity that qualifies for coverage of IRF care. 
 
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 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 a stroke. The enrollee's medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. 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 documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78811). 
 
You asked the Plan to pre-approve a PET scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET scan. Our reviewer says that a 
PET scan is not indicated at this time. Our physician reviewer found there is no documentation of any concern 
for malignancy, nodule morphology, or size or position of the nodules to warrant the requested PET scan. The 
enrollee does not have an indication for which a PET scan can be covered at this time. The requested is not 
PET scan medically necessary or reasonable for the enrollee at this time. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan (78811).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint arthrodesis. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has low back pain. There is 
no documentation of SI joint instability, fracture, or lesion. The criteria for SI joint fusion are not met. The use 
of SI joint fusion for degenerative low back pain is experimental. The services are therefore not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint arthrodesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre Continuous Glucose Monitor and 
supplies 
 
You asked the Plan to pre-approve the Continuous Glucose Monitor and supplies. You say that you would like 
reconsideration because these supplies are medically necessary to help treat the member's condition. The Plan 
denied your request. The Plan says the member does not meet Medicare coverage criteria for the continuous 
glucose monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day and require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the 
Continuous Glucose Monitor and supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the FreeStyle Libre Continuous Glucose Monitor and supplies