Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography (CPT Code 93306) provided to the enrollee 
on January 17, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollee is in a clinical trial. 
 
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. The services are associated with a 
clinical trial and the claim must be billed to Medicare as the primary payer, before the Plan can process the 
claim as the secondary payer. Therefore, we decided that the Plan does not have to pay for echocardiography, 
transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, 
complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography (CPT Code 
93306) provided to the enrollee on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day/Sensor/Flash Monitoring 
System with Reader. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 Day/Sensor/Flash Monitoring System with Reader. 
You say that the items 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 CGM devices are covered when specific criteria is 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Freestyle Libre 14 Day/Sensor/Flash 
Monitoring System with Reader. Our reviewer says that the items are not medically necessary. Our physician 
reviewer found the enrollee does not use insulin and most recently does not seem to be on any medication for 
diabetes mellitus (certainly not insulin) and it is not clear why a traditional glucometer does not suffice. 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 Freestyle Libre 14 Day/Sensor/Flash Monitoring System with Reader have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 
Day/Sensor/Flash Monitoring System with Reader.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone-growth stimulator.
You asked the Plan to pre-approve a bone-growth stimulator. You say that the item 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 an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 bone-growth stimulator. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the electric bone growth stimulator is medically necessary for this enrollee. The enrollee does not meet any of the required criteria for the electric bone growth stimulator (nonunion of long bone fractures; failed fusion, where a minimum of 9 months has elapsed since the last surgery; congenital pseudarthroses). 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 bone-growth stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone-growth stimulator.
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 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 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 available records, you do not meet Medicare coverage criteria for IRF
admission. You were medically stable with no evidence of need for supervision by acute physical, medicine,
and rehabilitation (PMR) or acute rehab nursing care. You may benefit from further physical therapy (PT) and
occupational therapy (OT) but does not require an intensive 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electroencephalographic recording (93229). 
 
You asked the Plan to pre-approve external mobile cardiovascular telemetry with electroencephalographic 
recording. 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 real-time outpatient cardiac telemetry is considered 
medically unnecessary if it is unlikely to provide clinical data or information beyond that which has already 
been obtained from a previous test or if other testing (e.g., ECG, 24 hour Holter, etc.) could be expected to 
provide the data/information needed for the diagnosis and/or treatment of the patient?s condition/symptoms. 
 
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 external mobile cardiovascular 
telemetry with electroencephalographic recording. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found continuous real-time monitoring by telemetry services such as Zio 
Patch is not medically necessary in this case since off-line analysis of a patient activated device, auto-triggered 
device or extended continuous Holter monitor should be sufficient to identify dysrhythmias without 
jeopardizing patient safety. Immediate recognition and reporting of dysrhythmias through a call center 
provided by real-time mobile telemetry services is not medically necessary in this case and has not been shown 
to improve health outcome compared to standard monitoring techniques. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of external mobile cardiovascular telemetry with electroencephalographic 
recording have not been met. Therefore, we decided that the Plan does not have to pre-approve external mobile 
cardiovascular telemetry with electroencephalographic recording (93229).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 600 units of Botox every 3 months.
You asked the Plan to pre-approve 600 units. You say that the increase in dosage was due to the delay in treatment. The Plan denied your request. The Plan says this medication is considered investigational at doses above 400 for the enrollee's diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 600 units. Our physician reviewer found that the enrollee is status post cerebrovascular accident (CVA) with spastic hemiplegia. The requested dosing of Botox is not FDA-approved for the enrollee's diagnosis. The use of the requested dose is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the requested dosing is not safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 600 units have not been met. Therefore, we decided that the Plan does not have to pre-approve 600 units of Botox every 3 months.
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 information provided supports the 
need for care in an LTACH. The Plan denied your request. The Plan says the guidelines for coverage have not 
been met. 
 
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 still requires acute hospital level of care services and is receiving 
appropriate care at the current acute care facility. The review has determined that the enrollee does not require 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 
There are no services available at the LTACH that the enrollee requires 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 the diagnosis and condition of the enrollee and 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 long-term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography with doppler complete 
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 are no heart related symptoms such as chest pain or shortness of breath. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee's echocardiogram in June 2019 showed no significant abnormalities at that time. Likewise, 
Likewise, there is no documentation to support the medical necessity for an additional echocardiogram in the 
medical records provided. 
 
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 a transthoracic echocardiography with doppler complete for the enrollee.
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 enrollee requires ongoing daily 
physician visits with adjustment in her treatment plan as needed. The Plan denied your request. The Plan says 
there is no evidence of acute and comorbid conditions requiring prolonged hospitalization. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with leukoencephalopathy suspected to 
be from cocaine use. She was found in cardiac arrest and returned to spontaneous circulation after 2 minutes. 
She was diagnosed with anoxic brain damage, acute respiratory failure, acute kidney failure with acute cortical 
necrosis, stage III pressure ulcer, thrombocytopenia, and ascites. She was treated with feeding tube and later 
TPN following imaging showing perforated viscera. She was treated with multiple antibiotics and is dependent 
on mechanical ventilation. She has failed weaning trials. The enrollee requires additional acute care services 
currently. Due to current use of TPN and not being a good candidate for weaning from mechanical ventilation, 
she is not a good candidate for LTACH transfer. She does not require services at the LTACH that are not 
already available at the current facility. Therefore, this request for LTACH services will be considered not 
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 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 long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the next step in your care 
and you cannot stay in the ICU forever. You say that you need to regain your strength. The Plan denied your 
request. The Plan says the guidelines for coverage have not been met. 
 
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 still requires acute hospital level of care services and is receiving 
appropriate care at the current acute care facility. The review has determined that the enrollee does not require 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 
There are no services available at the LTACH that the enrollee requires 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 the diagnosis and condition of the enrollee and 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 long-term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
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 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 
weakness associated with Parkinson's disease. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The record does support a need for 
physical and occupational therapy, but there is no need for an intensive rehabilitation 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. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve the Botox. You say that you would like reconsideration because this service 
is medically necessary. The Plan denied your request. The Plan says the member's symptoms are not consistent 
with either extrapyramidal disease (abnormal movements) or spasmodic torticollis 
 
The Plan follows Medicare rules. Medicare rules say that Botulinum toxin can be used to reduce spasticity 
related to spastic hemiplegia/hemiparesis, writer's cramp, dystonia such as extrapyramidal disease (abnormal 
movements) or spasmodic torticollis.  
 
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 Botox. Our reviewer says that the 
member does not meet Medicare criteria for Botox. Our physician reviewer found the records do not show that 
this member has conditions which would qualify as an indication by the LCD criteria for Botox use. 
 
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 Botox have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Botox.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient is living at home and receiving home 
health services. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. The record does support a need for physical and occupational 
therapy but there is no need for an intensive rehabilitation program. There is not a reasonable expectation that 
this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your needs can be met at an alternate 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 inpatient rehabilitation facility (IRF) admission and services.