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 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's needs could possibly be met 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 patient is currently medically stable with right great toe Osteomyelitis and cellulitis. There is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While she may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day at her functional level with frequent physician oversight and an interdisciplinary approach to rehabilitation care. 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 you need an intense rehab program. The Plan denied your request. The Plan says that your medical and therapy needs can be met at skilled nursing facility level.

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. You are currently medically stable with Debility after acute congestive heart failure. There is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While you may benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. You do not meet the Medicare coverage criteria for admission to an IRF based on lack of medical complexity. You do not need specialized skills of a rehab team. Your rehab needs can be met in a lower intensity alternate setting. Our physician reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the item is medically 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 CGM. 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 enrollee meets the coverage criteria for the continuous glucose monitor. The enrollee 
has not been performing frequent (four or more times a day) testing and there is no documentation that the 
enrollee's insulin treatment regimen requires frequent adjustment on the basis of glucose testing results. 
 
 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional occupational therapy visits. 
 
You asked the Plan to pre-approve 8 additional occupational therapy visits. You say that the enrollee is still in 
need of therapy. The Plan denied your request. The Plan says the enrollee no longer requires skilled therapy. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 8 additional occupational therapy visits. 
Our reviewer says that the requested occupational therapy visits are not medically necessary. Our physician 
reviewer found the patient's current functional level does not  indicate he requires the unique skills of a 
professional occupational therapist to safely and effectively provide treatment. These services do not need to 
safely and effectively be performed only by a therapist or under the supervision of a therapist. The patient has 
had therapy and was trained in a home exercise program. The requested services are not  part of a maintenance 
program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design or deliver a program to maintain the patient's current condition or to prevent or slow further 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 8 additional occupational therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promethazine HCL for the enrollee. 
 
You asked the Plan to pre-approve Promethazine HCL. You say that this is medically necessary. 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 Promethazine HCL for the 
enrollee.  
 
Benefits for Promethazine HCL 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
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 your needs can be met with services provided outside of a SNF setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
and of the cervical spine. 
 
You asked the Plan to pre-approve the MRI services. You say that the enrollee has complaints of neck and back 
symptoms. You say that the enrollee has neurology consultation because of these symptoms. You say that the 
enrollee has been complaining of fainting spells because of her symptoms. You say that, for these reasons, the 
requested MRI services are medically necessary. The Plan denied your request. The Plan says the clinical 
information provided does not describe the criteria for coverage have been met, and the requested MRI services 
are not indicated at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI services. Our reviewer says 
that the requested MRI services are not medically necessary. Our physician reviewer found there is no 
documentation of a recent trial and failure of physical therapy for neck and back pain. More conservative 
measures are needed and MRI services are not needed 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 the MRI services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine and of the cervical spine.
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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, skin and O2 care, and daily therapy can be provided at a SNF. In this case, you are 
mostly moderate/minimal assist for functional transfers and activities of daily living (ADL's) and a less 
intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and 
predicted period. An IRF intensity is not warranted. 
 
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: 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's medical and therapy needs can be met at skilled nursing 
facility level. 
 
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 
patient is currently medically stable with after an uncomplicated hip fracture. There is no evidence of complex 
medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute 
rehab nursing care. While she may benefit from continuing physical therapy (PT) and occupational therapy 
(OT), there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent 
physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee does not need 
specialized skills of a rehab team. The enrollee's rehab needs can be met in a lower intensity alternate setting 
such as in an skilled nursing facility. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of a wireless pulmonary 
artery pressure sensor for long-term hemodynamic monitoring (33289). 
 
You asked the Plan to pre-approve transcatheter implantation of a wireless pulmonary artery pressure sensor. 
You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not 
been established. Therefore, coverage criteria has not been met. 
 
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 transcatheter implantation of a wireless 
pulmonary artery pressure sensor. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy 
change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help 
reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about 
potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is 
uncertain at this time according to leading authorities and not recommended in current guidelines for the 
treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered 
experimental or investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcatheter implantation of a wireless pulmonary artery pressure sensor have 
not been met. Therefore, we decided that the Plan does not have to pre-approve transcatheter implantation of a 
wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine injections (62323). 
 
You asked the Plan to pre-approve spine injections. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
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 spine injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no recent imaging or physical therapy (PT). This does not meet coverage criteria and 
therefore, the request is considered 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 spine injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine injections (62323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a esophagogastroduodenoscopy (EGD) (43235) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve an EGD to be provided by an OON provider. You say that the service is 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
this service. Therefore, coverage criteria has not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a esophagogastroduodenoscopy (EGD) (43235) to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Depakote ER. 
 
You asked the Plan to pre-approve Depakote ER. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says Depakote ER is not eligible for coverage under the Part B medical benefit. 
 
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 Depakote ER.  
 
Benefits for Depakote ER may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
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 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 is ambulating hundreds of feet. The enrollees 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a kyphoplasty is covered when specific criteria 
are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that the 
enrollee's fractures are not new fractures. They are more than six weeks old. The recent literature also shows 
that the requested procedure is not effective. The criteria for multiple kyphoplasty are not met and 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 kyphoplasty.