Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve an MRI of the brain. We decided that the Plan does not have to 
pre-approve an MRA of the brain.  
 
You asked the Plan to pre-approve an MRI of the brain. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
We decided that the Plan has to pre-approve an MRI of the brain. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Part C Plan was correct 
in denying the request to pre-approve an MRI of the brain. Our reviewer says that the requested service is 
considered medically reasonable and necessary in this case. Our physician reviewer found while the degree of 
cognitive decline has not been quantified the memory loss and the apraxia together are of concern enough to 
warrant MRI of the brain including contrast to rule out metastatic disease as a cause. 
 
Therefore, we decided that the Plan has to pre-approve an MRI of the brain.  
 
We also decided that the Plan does not have to pre-approve an MRA of the brain. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Part C Plan 
was correct in denying the request to pre-approve an MRA of the brain. Our reviewer says that the requested 
service is not considered medically reasonable and necessary in this case. Our physician reviewer found the 
request for an MRA is not substantiated within the records. The records do not show evidence of trigeminal 
neuralgia and there are no findings to imply facial nerve abnormality. 
 
Therefore, we decided that the Plan does not have to pre-approve an MRA of the brain. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: 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 the enrollee's 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 based on the medical records provided 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. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says based on the records provided, there is no evidence of 
limitations of strength, endurance, range of motion or coordination, deformity or absence of one or both upper 
extremities to self-propel a manual wheelchair, use of a cane or a walker. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power wheelchair.
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. The Plan denied your request. The Plan says you do not have a 
need for physician supervision, or a multidisciplinary team for 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 physician reviewer found 
that you are at a minimal to standby assist for bed mobility, and contact guard assist for bed-to-chair transfers. 
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. 
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level 
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The 
enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a 
"daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an 
inpatient basis, in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve powered upper extremity range of motion assist device, 
elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and 
accessories, custom fabricated (CPT Code L8702). 
 
You asked the Plan to pre-approve the powered upper extremity. You say that you are requesting review of 
denial of services. The Plan denied your request. The Plan says this is experimental. 
 
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 powered upper extremity. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation is insufficient to demonstrate that a powered upper 
extremity range of motion assist device is medically reasonable and necessary for you in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the powered upper extremity have not been met. Therefore, we decided that the 
Plan does not have to pre-approve powered upper extremity range of motion assist device, elbow, wrist, hand, 
finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom 
fabricated (CPT Code L8702).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee would be most likely to return 
to independent living if provided daily therapy in a SNF. The Plan denied your request. The Plan says the 
enrollee does not require daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to an 
acute care inpatient hospital on 9/21/2020 for the evaluation and treatment of congestive heart failure 
exacerbation in the setting of known oxygen dependency. She was medically stabilized and switched to oral 
Lasix. The patient does not require skilled nursing services with the specialized skill, knowledge and judgment 
of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment in a SNF.  The patient does not have complex wound care or other ongoing SNF level SN need. The 
patient's functional level does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of 
these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary 
services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services beginning 
October 6, 2020. 
 
You asked the Plan to pre-approve these services. You say that the enrollee would be in danger of harm if 
released. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on September 21, 2020 with unspecified psychosis. Based on the submitted records, it is not expected 
that she will improve in a reasonable period of time beyond the dates in question, as she does not have suicidal 
or homicidal ideation and has no auditory or visual hallucinations. She continued to have paranoia and 
delusions but is not a danger to herself or others. The continued services are 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 continued inpatient psychiatric services beginning October 6, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided at a lower 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. The 
enrollee is generally medically stable postop from spine surgery with no evidence of medical or nursing needs 
for an IRF and her current functional status does not require IRF level of therapies. There is no evidence of 
medical issues that require monitoring by an inpatient rehab physician three times a week. The documentation 
does not support that there is a need for an intensive therapy program with 3 hours a day and an 
interdisciplinary approach to rehab care. At supervision and complete guard assist for all mobility, the enrollee 
does not need IRF level of therapies and has no medical complexity. The enrollee's rehab needs can be safely 
and effectively met in an alternate, less intense setting. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sleep study, simultaneous recording of ventilation, 
respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist (CPT Code 95807). 
 
You asked the Plan to pre-approve the sleep study. You say that you are upset that you cannot get the sleep 
study. The Plan denied your request. The Plan says you are upset that you cannot get the sleep study. 
 
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 sleep study. Our physician reviewer 
found the coverage criteria for attended diagnostic PSG are not met. You have congestive heart failure (CHF) 
due to non-ischemic cardiomyopathy, with intermittent ventricular tachycardia and an implanted defibrillator.  
There is no mention in the record of excessive daytime sleepiness, snoring, observed apneas, or other sleep-
related symptoms. The reason for ordering the PSG is not indicated. Of note, if a PSG were indicated, it would 
need to be attended (in-lab) because of the CHF and arrhythmias. However, a diagnostic PSG is considered not 
medically necessary because there is no justification in the medical record. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, 
and oxygen saturation, attended by a technologist (CPT Code 95807).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the enrollee is currently using a donated 
wheelchair which was not fitted for him and is currently in disrepair. A new customized power wheelchair is 
medically necessary. The Plan denied your request. The Plan says Medicare payment cannot be made for DME 
for use in a nursing facility as this does not meet the definition of the enrollee's home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the power wheelchair is being requested for use in a SNF. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair with accessories.
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. The Plan denied your request. The Plan says IRF admission 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 that the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 a Vertiflex Superion spacer. 
 
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 requested Vertiflex Superion spacer 
is considered experimental/investigational in nature, as more research is needed to show safety and efficacy. 
There is no documented spinal instability. The services are 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 a Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral SI joint injections. 
 
You asked the Plan to pre-approve bilateral SI joint injections. You say that the requested bilateral SI joint 
injections are medically necessary. The Plan denied your request. The Plan says the requested bilateral SI joint 
injections 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 bilateral SI joint injections. Our 
reviewer says that the requested bilateral SI joint injections are not medically necessary. Our physician 
reviewer found the enrollee has chronic SI joint pain. He is taking NSAIDs, Oxycodone and a Lidocaine patch. 
He had SI joint injections on 8/26/20 and achieved 60% pain relief for less than 4 weeks. The request is for 
repeat SI joint injections. The enrollee only achieved 60% pain relief for less than 4 weeks. Therefore, the 
request is deemed not medically reasonable or 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 bilateral SI joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bilateral SI joint injections.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The 
enrollee'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 inpatient rehabilitation facility (IRF) admission and services.