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

We decided that the Plan has to pre-approve myocardial perfusion imaging, tomographic (SPECT) (including
attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique,
additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic)
and/or redistribution and/or rest reinjection (CPT Code 78452).
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan
denied your request. The Plan says that the service is not 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 the service. Our physician reviewer
found the patient has multiple risk factors for coronary artery disease (CAD) along with paroxysmal atrial
fibrillation (AF) as well. The patient's baseline electrocardiogram (EKG) is abnormal and could very well be
consistent with underlying, undiagnosed ischemic heart disease. Although the patient does not report angina,
they have had episodes of palpitations with PAF. The patient's baseline EKG abnormalities markedly limits the
interpretation and specificity of an EKG stress test. In addition, the patient has limited exercise tolerance and
required beta blocker therapy for the patient's AF make a chemical perfusion nuclear scan necessary to fully
assess for ischemic heart disease in this high risk patient. Based on these issues, an imaging study, in this case a
chemical myocardial perfusion nuclear scan to rule out underlying CAD (especially as a cause of his PAF) is
reasonable and medically necessary and fits with the requirements.
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 been met. Therefore, we decided that the Plan has to preapprove
myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or
quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when
performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest
reinjection (CPT Code 78452).
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: 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 admission to a SNF. You say that the requested admission to a SNF is 
medically necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical 
history of hypertension, depression, arthritis and dementia who presented to the acute hospital on 08/29/2020 
with right lower extremity cellulitis and ulcers. He was treated in the hospital with intravenous antibiotics and 
then transitioned to Augmentin. He is now back in his long term care facility for care. His right heel wound 
care consists of normal saline cleansing and hydrogel with a foam dressing. He is weak and deconditioned and 
has been evaluated by physical and occupational therapy. He is non-ambulatory and requires a Hoyer for 
transfers and is maximum assist for activities of daily living. He is medically stable. Reports from the facility 
indicate he is combative and uncooperative with staff due to his dementia. 
 
 
 
Based on the medical records provided there is no documentation that the enrollee requires skilled nursing 
services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse is not required to 
safely and effectively provide medically necessary and reasonable treatment. Based on the medical records 
provided this enrollee does not require skilled therapy services, i.e., the specialized skill, knowledge and 
judgment of a qualified therapist is not required to safely and effectively provide medically necessary and 
reasonable treatment. Based on the medical records provided daily skilled services are not required. Based on 
the medical records provided this enrollee does not require the 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 admission to a SNF 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Ozurdex dexamethasone intravitreal implant. 
 
You asked the Plan to pre-approve the Ozurdex implant. You say that the enrollee would benefit from the use 
of this treatment. The Plan denied your request. The Plan says that there is no literature support for this 
treatment for the enrollee's condition. 
 
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 the Ozurdex implant. Our reviewer says 
that the requested treatment is deemed reasonable and necessary for the enrollee's condition. Our physician 
reviewer found It is medically necessary for the patient to have treatment with the Ozurdex implant based on 
appropriate off-label use of this drug for this condition that is also supported by evidence in the medical 
literature. there is good evidence in the medical literature that post-vitrectomy use of Ozurdex is beneficial for 
patients with refractory macular edema after epiretinal membrane peel.  Although initial studies of the Ozurdex 
implant and subsequent approval and indications were based on its use in diabetic retinopathy or macular 
edema associated with vein occlusion, there is a newer body of evidence published since then that demonstrates 
good safety and efficacy with this patient?s disease.   
 
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 Ozurdex implant have been met. Therefore, we decided that the Plan has to 
pre-approve Ozurdex dexamethasone intravitreal implant.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services, for the enrollee. 
 
You asked the Plan to pre-approve home health aide services. You say that there does not seem to be many 
doctors in your area who deal with elderly patients with these sorts of issues. The Plan denied your request. The 
Plan says the enrollee is already receiving Home Health Services with an in-network provider. The Plan states 
the need for Home Health Aide services appears to be custodial in nature and there is no order from the 
enrollee's physician requesting home health aide services and the provider is non-participating with the plan. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health aide services. Our 
physician reviewer found the records do not show that skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a 
maintenance program to maintain the patient's condition and/or prevent deterioration.  The records do not show 
that skilled therapy is needed to effectively provide treatment, care, and/or services in order to improve the 
patient's level of function, or to establish/perform a maintenance program to maintain the patient's level of 
function and/or prevent deterioration. As the patient does not require skilled therapy or skilled nursing services 
and the documentation is not clear that the patient is homebound the patient does not meet the definition of 
home health aide services per Section 50.2 and the request for home health aide services are not reasonable and 
necessary to the treatment of the patient's illness or injury by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services, for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that the requested Gel-One is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for Gel-One. 
 
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 Gel-One. Our reviewer says that the 
enrollee does not meet criteria for Gel-One. Our physician reviewer found this enrollee presents with a history 
of bilateral knee pain, worse with weight bearing and climbing stairs. Conservative treatment has included ice, 
rest, NSAIDs, and cortisone injections which have historically provided significant relief. There is reported 
radiographic evidence of moderate tricompartmental osteoarthritis in both knees, worse in the medial 
compartments. Under consideration is a request for Gel One. Medicare coverage criteria have not been fully 
met as outlined above. There is no current pain or functional assessment documented in the submitted medical 
records. There is no radiographic evidence of osteoarthritis, such as joint space narrowing, subchondral 
sclerosis, osteophytes, and/or subchondral cysts. There is no evidence that the enrollee had failed to respond to 
the most recent cortisone injections performed at the time of the request. Given the absence of documented 
failure of/or contraindication to conservative therapy and/or corticosteroid injection in the medical record, 
Medicare would not consider viscosupplementation medically reasonable and necessary. Therefore, this 
enrollee does not have a covered indication for the requested Gel One at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 75mg Nurtec Tablets. 
 
You asked the Plan to pre-approve the Nurtec. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's 
condition under Medicare 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 75mg Nurtec Tablets.  
 
Benefits for the Nurtec 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 10 physical therapy visits. 
 
You asked the Plan to pre-approve the additional 10 physical therapy visits. You say that you require physical 
therapy with therapists experienced in rotator cuff tears. You say that you still have profound weakness but are 
able to lift 1 lb weights and have had an increased range of motion and strength. The Plan denied your request. 
The Plan says ongoing physical therapy is not medically necessary. The Plan says that after 40 physical therapy 
visits this enrollee has made minimal gains and has unchanged deficits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional 10 physical therapy 
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found there is no indication that prior physical 
therapy has served to provide sustained, significant improvement in pain and/or function and there is no 
indication residual deficits could not be addressed via a home exercise program. Therefore, this request is 
deemed 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 additional 10 physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an additional 10 physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the portable concentrator. You say that you feel this should be covered. The 
Plan denied your request. The Plan says although you may meet criteria for portable oxygen tanks, there is no 
need for a second oxygen concentrator. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a stationary oxygen concentrator for use in the home. The Plan has indicated that 
portable oxygen tanks would be approved if requested. Since you already possess a concentrator, a second 
concentrator is duplicative as this function can be provided through portable tanks. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
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 was referred to the LTACH 
for aggressive medical management with their interdisciplinary team approach. You say that, because of the 
LTACH's specialized and medically complex trained staff, the enrollee is expected to do well in this setting. 
The Plan denied your request. The Plan says LTACH services are not medically necessary. The Plan says that 
enrollee's care can be safely managed in the current care setting. 
 
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 in this case appears to be trialing weaning, but still requires additional 
acute care services and weaning before determining if she will be vent dependent. However, the documentation 
does not suggest that the enrollee is likely to warrant acute care services beyond 24 additional days in order to 
determine this, and she is clinically stabilizing. The enrollee does not require services at the LTACH that are 
not already available at the current facility. Continued services at the current facility appears to be most 
appropriate and consideration for transfer to a lower level of care can be made soon. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with related harness and 
electronic connections for an approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller and related hardware. You say that the wheelchair 
and requested components are necessary and should be approved. The Plan denied your request. The Plan says 
all requested items have been approved aside from the expandable controller which is 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 the expandable controller and related 
hardware. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a history of paraplegia with right sided hemiparesis 
and has an approved power wheelchair.  The requested power controls permit operation through the joystick in 
addition to standard switch operators.  Documentation does not support the enrollee's need for additional 
joystick controls for the power tilt, recline, and elevation of leg rests. The enrollee is noted to have 5/5 strength 
on the unaffected side. 
 
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 expandable controller and related hardware have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller with related harness and 
electronic connections for an approved power wheelchair.
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 the enrollee is with a past 
medical history of myelodysplastic syndrome with anemia and thrombocytopenia who presented to the acute 
hospital on 09/03/2020 with shortness of breath, abdominal pain, fever and chills related to pneumonia and 
diverticulitis. He was treated in the hospital with intravenous antibiotics, nebulizers and supplemental oxygen. 
He also has had acute kidney injury which has improved with fluids. His condition has improved and his 
oxygen requirement is down to 2-3 liters nasal canula. He is weak and deconditioned and is working with 
physical and occupational therapy. He is walking 50 feet with a wheeled walker with minimum assistance and 
is minimum assist for transfers and activities of daily living. He is medically stable. 
 
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. 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the 
medical records provided there is no documentation that the enrollee requires the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility. 
 
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.