Persius/hicric huggingface dataset:
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 the SNF services. You say that the records provided support the need for 
SNF care. The Plan denied your request. The Plan says the enrollee is medically stable and does not have 
skilled needs at this point. 
 
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 services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral 
medications and enteral nutrition. The enrollee had stable vital signs and clear lungs. The enrollee received 
physical therapy, speech therapy, and occupational therapy in the SNF. By the dates in question, the enrollee 
was at an independent with transfers and at a stand-by-assist for gait to 200 feet. The enrollee required varying 
assist with activities of daily living. There are identifiable skilled nursing service needs, but they are not 
required on a daily basis. There are no identifiable skilled therapy service needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option
You asked the Plan to pre-approve the wheelchair. You say that you are appealing the denial for the electric
wheelchair. The Plan denied your request. The Plan says the enrollee has a manual wheelchair and a Rover at
home and does not meet the medical necessity criteria
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.
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 wheelchair. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found The group 3 power wheelchair with single power option K0856 is not medically necessary as
the documentation does not support that the Local Coverage Determination (LCD): Power Mobility Devices
(L33789) for the K0856 has been met. The patient has a mobility limitation that impairs MRADLS in the home
and the documentation states the patient does not have sufficient upper mobility strength to self-propel a
manual wheelchair or use a cane or walker. The documentation does not support that this mobility limitation is
due to a neurological condition, myopathy, or congenital skeletal deformity therefore the patient does not meet
the criteria for the requested device.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair with single power option.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tenex procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered experimental and investigational. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee presents with recurrent right lateral-sided hip pain. She has been diagnosed with 
gluteal tendinitis of the right hip. She has reportedly failed to improve with long-term conservative treatment, 
including activity modification, rest, ice, and home exercise. A cortisone injection on 10/31/19 provided 
approximately 5 weeks of relief, followed by recurrence of pain. Under consideration is a request for the Tenex 
procedure for the right hip. Medicare coverage criteria have not been met. A search of PubMed documented 
one case study specifically addressing the use of percutaneous ultrasonic tenotomy for patients with gluteal 
tendinopathy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
this procedure for this enrollee's medical condition as safe and effective. This procedure would be considered 
investigational for this enrollee's medical condition. Therefore, this request for the Tenex procedure for the 
right hip would not be considered medically reasonable and 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Tenex procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation including cavity
creation services.
You asked the Plan to pre-approve percutaneous vertebral augmentation including cavity creation services.
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the
requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation including cavity
creation is only covered for certain indications.
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 percutaneous vertebral augmentation
including cavity creation services. Our reviewer says that the documentation does not support that the
requested injection services are medically reasonable or necessary. Our physician reviewer found you have 5
osteoporotic vertebral body compression fractures (T12,L1,L2,L4,L5). Per the documentation, you are walking
with a cane and the pain level is a 9 out of 10. An MRI received on July 28, 2020 showed several acute or
incompletely healed compression/endplate deformities of the T11-L5 vertebral bodies with the exception of L3
which appears normal. The T11 and L4 vertebral bodies appear most affected. The documentation does not
support that you have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of
injection services as you have greater than three vertebral fractures, which is a contraindication to this
procedure. Therefore, you do not meet criteria for the requested 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 percutaneous vertebral augmentation including cavity creation services have not
been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral
augmentation including cavity creation services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
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 BRCA testing 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 enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has a history of 
breast cancer diagnosed at age 70. There is no evidence of a family history of cancer at a young age. The 
criteria for coverage are not met and the requested BRCA testing is not reasonable or medically necessary for 
the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA genetic testing.
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 want to go to this facility because it is free of
COVID-19. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 be able or willing to perform 15 hours per week of rehabilitative services with regular physician
evaluation. Your care needs can be met at a lower level of care such as skilled nursing facility or sub-acute
rehabilitation.
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 has anemia secondary to 
chronic kidney disease. He has not tried and failed the Plan's required drug of Retacrit. The records do not 
show that the required drug would be contraindicated or less effective; therefore, Aranesp is not reasonable or 
medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
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 would like the plan to reconsider their denial 
The Plan denied your request. The Plan says the requested 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 the enrollee required supervision for bed mobility and transfers. The enrollee 
required minimal assistance of two with walking 7-8 feet with a rolling walker. The enrollee was dependent for 
toileting. The enrollee required moderate assistance with upper body dressing and moderate to maximum 
assistance with lower body dressing. 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's medical status does not currently require intensive physician and nursing oversight only in an IRF. 
The enrollee may benefit from multiple therapies such as physical and occupational therapy, but the 
documentation does not support that the enrollee's endurance level can tolerate an 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 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. 
 
You asked the Plan to pre-approve IRF care. You say that it is felt that IRF care would be the most appropriate 
option. The Plan denied your request. The Plan says the enrollee does not require this 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 the enrollee was discharged from a hospital on 7/31/2020 with a sacral pressure ulcer 
and was readmitted with weakness and repeated falls. The enrollee is now hemodynamically stable, but 
debilitated. The enrollee is non-toxic, and mostly minimal/moderate assist for care. Records do not indicate that 
there are significant, or complex medical/nursing issues that require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. In this case, the member is mostly moderate to minimal assist 
for functional transfers and daily living activities and a less intensive, longer duration of therapy will allow for 
measurable gains to be attained within a reasonable, and predicted period. 
 
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 additional OneTouch Ultra Blue test strips for the 
enrollee. 
 
You asked the Plan to pre-approve the additional supply. You say that this is medically necessary. The Plan 
denied your request. The Plan says the calculated amount appeared to be either above the covered amount, or 
had an unusual dispensing interval. 
 
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 additional supply. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the submitted documentation notes the enrollee has a diagnosis of diabetes mellitus 
type 2 with diabetic polyneuropathy. The plan has approved 150 strips as a 30 day supply. Review of 
documents notes the enrollee filled the script on 7/1/20. A refill within 30 days exceeds the approved 
prescription and exceeds the medical necessity for strips. 
 
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 supply have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional OneTouch Ultra Blue test strips for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental extraction to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve these dental services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
dental extraction to be provided by an oral surgeon.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the chest and a CT scan of the abdomen/pelvis.
You asked the Plan to pre-approve the CT scans. You say that this is needed due to the high risk of malignancy
given the patient's findings. The Plan denied your request. The Plan says that there are not sufficient findings to
support this imaging.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scans. Our reviewer says that
these imaging studies are considered reasonable and necessary for this patient. Our physician reviewer found
the enrollee has had a more than 10% unintentional weight loss with unexplained anemia, along with a long
smoking history. Due to these risk factors and signs/symptoms, this imaging is considered necessary. In
addition, as he is not able to tolerate a colonoscopy, inclusion of the abdomen/pelvis in this case is also
reasonable.
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 CT scans have not been met. Therefore, we decided that the Plan has to preapprove
a CT scan of the chest and a CT scan of the abdomen/pelvis.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of IRF care 
because the records do not show a complex medical problem that requires and inpatient rehabilitation. The Plan 
says that the IRF stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly 
moderate to minimal assist for functional transfers and activities of daily living. A less intensive, longer 
duration of therapy will allow for measurable gains to be attained within a reasonable and predicted period. The 
intensity of an IRF 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.
You asked the Plan to pre-approve IRF care. You say that the documentation provided supports the need for IRF care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF as she does not require 24 hour, 7 days a week supervision/care from a rehabilitation physician or nursing staff. The Plan says that the enrollee's therapy needs can be met 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. Our physician reviewer found the 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 medication management, oxygen care, and daily therapy can be provided at a SNF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.