Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires bed assistance and assistance 
with mobility. The appellant says that the enrollee's family is unable to provide assistance. The appellant says 
that IRF care is medically necessary. 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 enrollee is generally medically stable with no evidence of need for a physical 
medicine and rehabilitation physician's monitoring 3 times a week or needs acute rehab nursing care. He needs 
minimal physical therapy and occupational therapy for functional recovery. While he may benefit from 
continuing physical therapy and occupational therapy at home or safety education, there is no documented 
evidence of a need for an intensive therapy program with therapy 3 hours per day with frequent physician 
oversight and an interdisciplinary approach to rehabilitation care. Admission to an IRF is not medically 
necessary based on lack of medical complexity and current functional status in mobility. The enrollee's rehab 
needs can be met at an alternate, low intensity level setting such as in an skilled nursing facility (SNF). 
 
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 insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (CPT Code 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is experimental and more research is needed to show safety and efficacy. 
 
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869) 
and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression 
or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiovascular stress test using maximal or submaximal 
treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with 
supervision, interpretation and report (CPT Code 93015). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Stress Test cannot be approved with MPS for evaluation. 
 
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 service. Our physician reviewer 
found LCD L35083 states that tests that are anticipated to provide information duplicative of another test 
already performed will be denied as not medically necessary. A cardiovascular stress test would be anticipated 
to provide information duplicative of results of a TTE and MPS. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, 
continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and 
report (CPT Code 93015).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy; initial assessment and 
intervention, individual, face-to-face with the patient, each 15 minutes (CPT Code 97802) and medical 
nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 
(CPT Code 97803). 
 
You asked the Plan to pre-approve the services. You say that you would like guidance from a nutritionist to 
help you keep a healthy weight during your chemotherapy process. The Plan denied your request. The Plan 
says nutritional counseling is only covered benefit when the member has diabetes (too much sugar in the 
blood), or if the member has kidney disease, or after a kidney transplant. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you do not meet criteria for assessment and evaluation with nutritionist. You have self-
requested this for the purpose of weight loss. There is no indication in the medical records by the physician for 
a need for weight loss and a diagnosis that would prompt this referral. 
 
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 medical nutrition therapy; initial assessment and intervention, individual, face-to-face with 
the patient, each 15 minutes (CPT Code 97802) and medical nutrition therapy; re-assessment and intervention, 
individual, face-to-face with the patient, each 15 minutes (CPT Code 97803).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab (J9271). 
 
You asked the Plan to pre-approve Pembrolizumab. You say that the medication is 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 a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Pembrolizumab. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found this enrollee's tumor mutational 
burden was less than 10 and not clearly on an FDA approved platform. The service is 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 Pembrolizumab have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Pembrolizumab (J9271).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. You are receiving appropriate care at the present acute care facility and when considered medically 
stable by the treating team will be an appropriate candidate for care at a less intense level such as home with 
services. The review has determined that you do not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving care. There are no services available at the LTACH that 
you require that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and 
are able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 based on the documentation provided, the health plan's denial should be upheld. The 
patient does not require the intensity of services provided at an IRF. Specifically, the patient is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The patient's care 
needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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 of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. 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 an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD. 
 
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 of the brain. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found CMS has strict criteria for the 
approval of PET imaging in enrollees with cognitive decline. There is a requirement of a differential diagnosis 
of Alzheimer disease vs. FTD however this enrollee does not have such a differential. In fact, the requesting 
physician indicates Lewy Body Dementia is in the differential. CMS specifies that PET imaging is not covered 
for other neurodegenerative diseases other than AD and FTD. Specifically CMS does not cover the scan when 
there is a clinical consideration of Lewy Body Dementia per NCD guidelines. 
 
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 of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EW-36 Elite power scooter. 
 
You asked the Plan to pre-approve the power scooter. You say that you have dizzy spells and have fallen many 
times in the house and are afraid you would fall outside. You state you are stuck in your home for fear of 
falling. The Plan denied your request. The Plan says the records provided for your appeal indicate that you are 
currently ambulating within your home. The Plan states there is no documentation provided that indicates a 
walker or other assistance device (like a standard wheelchair) could not be used in the home.  The Plan states 
there was no documentation provided indicating a home evaluation has been completed to show your home 
could support the use of an electric scooter. The Plan states the specific scooter that was requested has 
capabilities that are not needed for use in the home, therefore the specific scooter being requested is not a 
covered item. 
 
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 power scooter. Our physician 
reviewer found the documentation does not support that you have a personal mobility deficit that impairs your 
participation in MRADLs such as toileting, feeding, grooming and bathing in customary locations within the 
home. The documentation does not support that you cannot be helped by the use of a walker, cane or manual 
wheelchair.  It is not documented that you can safely operate a power mobility device (PMD). Therefore, the 
Medicare rules have not been met. Furthermore, the provider you are requesting from is not a Medicare 
provider. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve EW-36 Elite power scooter.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that there are no intense and complex care needs that make recovery facility 
care safer and more practical than attempting care at a lower level. 
 
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 that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 based on the documentation provided, the health plan's denial of LTACH coverage 
should be upheld. The patient is currently undergoing treatment at an ACH for chronic cardiac and respiratory 
disease. The patient is not intubated.  The patient is on supplemental oxygen and non-invasive ventilation. 
There is no evidence that the patient requires services that are not currently available. As LTACHs and ACHs 
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 
The patient can remain at the current ACH until such time no acute services are required. The patient can then 
be transferred/discharged to a lower level of care for any ongoing LTC needs. 
 
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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a right knee arthroscopy. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has persistent right knee pain 
with associated mechanical symptoms of buckling, catching and giving out. Clinical exam findings are 
consistent with imaging evidence of a complex medial meniscus tear and loose bodies. There is imaging 
evidence of chondromalacia patella with associated full thickness cartilage loss with subchondral/subcortical 
bone cystic change of the patella apex and lateral facet. She has reportedly failed long-term extensive 
conservative treatment. Current evidence based medical literature supports surgical intervention at this time 
based on her mechanical complaints, physical exam, imaging findings, and failed conservative treatment. The 
requested knee arthroscopy is therefore reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve a right knee arthroscopy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve QVAR RediHaler for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this has been controlling the enrollee's breathing 
issues well. 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 QVAR RediHaler for the 
enrollee.