Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve therapeutic facet joint injections. 
 
You asked the Plan to pre-approve therapeutic facet joint injections. You say that therapeutic facet joint 
injections are medically necessary. The Plan denied your request. The Plan says that criteria for therapeutic 
facet joint injections are not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of injection.  
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 therapeutic facet joint injections. Our 
reviewer says that therapeutic facet joint injections are medically necessary. Our physician reviewer found the 
medical records show that you have probable facet mediated pain. Diagnostic facet injections are indicated for 
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 therapeutic facet joint injections have been met. Therefore, we 
decided that the Plan has to pre-approve therapeutic facet joint injections.  
 
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 Horizant tablets. 
 
You asked the Plan to pre-approve the Horizant tablets. You say that the enrollee is currently being treated with 
Gabapentin but cannot continue to take it due to it making her sick. You say that the enrollee has tried samples 
and it has worked wonderfully. You say that the enrollee has no contraindications to Horizant. The Plan denied 
your request. The Plan says the drug in dispute is not covered under Part B coverage. 
 
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 Horizant tablets.  
 
Benefits for the Horizant tablets 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 acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The 
documentation does not support that the enrollee's functional status currently requires an intensive 
rehabilitation therapy program provided in an IRF. Recent therapy notes indicate ambulation of 250 feet with 
RW and SBA-CGA for transfers. Medicare coverage criteria for IRF care are not met. 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve the inpatient psychiatric care. You say that inpatient psychiatric services are 
medically necessary. The Plan denied your request. The Plan says the clinical information provided does not 
support the requested level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the inpatient psychiatric care. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was 
admitted to the acute inpatient psychiatric hospitalization on September 5, 2020 with Alzheimer's Disease As 
Probable Etiology of Dementia, Major Neurocognitive Disorder with Behavioral Disturbance, Psychosis 
Unspecified Although Likely Natural Progression of Dementia. Based upon review the records provided it was 
not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not 
have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was 
compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary 
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care beyond the dates in question as she did not have dangerousness to self or others but was compliant with 
her treatment. This enrollee did not appear to require inpatient mental health treatment beyond the date in 
question as she was not a danger to herself or others and did not have any auditory or visual hallucinations 
while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date 
in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or 
for the purpose of diagnosis beyond the date in question. 
 
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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories (harness, electrical 
connection, expandable controller) for the enrollee. 
 
You asked the Plan to pre-approve the requested accessories. You say that these accessories are medically 
necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met, 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for these types of accessories.  
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 accessories. Our reviewer 
says that Medicare coverage criteria are not met. Our physician reviewer found the E2377 Expandable 
Controller and E2313 Expandable Controller Harness are not medically necessary per Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52504). The documentation does not reveal that the 
enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, 
touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, 
etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a  
separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative 
speech device or computer through the chair's drive control), or an attendant control. The documentation 
indicates the enrollee can feed and groom herself independently. This functional ability would allow her to 
control any power options on the wheelchair with their own switches. Additionally, the documentation 
submitted has conflicting information between the PA-C note and the wheelchair face to face OT note 
regarding enrollee's range of motion. The OT note states the patient has severely limited range of motion and 
the PA-C note states that the enrollee has normal range of motion under the musculoskeletal review of systems 
part of the progress note. Based on inconsistency in the records provided, Medicare coverage criteria are not 
met. 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 accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve power wheelchair accessories (harness, electrical connection, expandable 
controller) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651) and 
segmental pneumatic appliance (E0668). 
 
You asked the Plan to pre-approve a PCD and segmental pneumatic appliance. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee has not failed conservative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that PCDs and related accessories are covered when 
the lymphedema is then documented to be unresponsive to other clinical treatment over the course of a required 
four-week trial. 
 
We looked at the file and Medicare rules. The submitted medical records do not show the enrollee has failed 
four weeks of conservative treatment as defined above. Based on this information, we decided that Medicare 
rules for coverage of a PCD and segmental pneumatic appliance have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651) and segmental 
pneumatic appliance (E0668).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that a spinal cord stimulator is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for a spinal cord stimulator.  
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 spinal cord stimulator. Our reviewer 
says that Medicare coverage criteria are not met. Our physician reviewer found the medical records show the 
enrollee has chronic low back pain. The medical records do not show the enrollee meets all of the required 
criteria as stated above. Medicare coverage criteria are not met. 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 spinal cord 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord 
stimulator for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation to support the medical necessity for continued skilled services 
of any type at this time. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
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 admission. You say that this is medically necessary to regain strength 
after a foot fracture. The Plan denied your request. The Plan says needs can be met in a lower level of care, 
with skilled intermittent therapy and nursing in a community setting. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is necessary. The Plan denied your 
request. The Plan says Medicare coverage criteria are not 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The 
documentation does not support that the enrollee's functional status or endurance level can tolerate or requires 
an intensive rehabilitation therapy program provided in an IRF. Medicare criteria are not met. 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 for the enrollee.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an elliptical machine. 
 
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 exercising outside of your home can be dangerous due to the pandemic. 
 
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 an elliptical machine.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not 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 services. Our reviewer says that daily skilled services are not necessary. Our physician 
reviewer found there are no identifiable skilled therapy service needs. The enrollee does not require skilled 
nursing or therapy services on a daily basis.  The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria are not met.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Modafinil tablets. 
 
You asked the Plan to pre-approve the Modafinil. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the drug being requested is not covered under Part B. The Plan says that the 
enrollee does not have Part D coverage under their contract. 
 
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 Modafinil tablets.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0668). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are 
requesting an appeal regarding denial of coverage for the Flexitouch pneumatic compression pump prescribed 
to treat lymphedema. The Plan denied your request. The Plan says the requested services does not meet the 
criteria as she has not completed a 4-week trial of conservative therapy demonstrating failure to respond to 
treatment with E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0668).
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
lumbar surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. Your do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medicare 
coverage criteria are not met. 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.