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. 
 
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 requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. The enrollee continues to have a 
need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that he would require skilled rehabilitation in an IRF, participating in rehab 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain his functional status. He can receive further services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second epidural steroid injection. 
 
You asked the Plan to pre-approve a second epidural steroid injection. You say that this is medically necessary. 
The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat epidural steroid injections may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using same scale for at 
least three months.  
 
We looked at the file and Medicare rules. The record shows that the enrollees first injection was on June 28, 
2022. Fewer than three months have passed since this injection. Based on this information, we decided that 
Medicare rules for coverage of a second epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a second epidural steroid injection.
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 are appealing with supporting records. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient's medical conditions appear stable on outpatient medications with no issues 
that appear to require a physician's evaluation three or more times per week. Our physician reviewer also found 
that the provided medical records do not explain why the intensive inpatient rehabilitation therapy program is 
necessary and why therapy at a lower level of care such as in a skilled nursing facility is not appropriate for this 
member. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve an injection. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
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 
an injection to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the clinical information submitted supports the 
medical necessity for SNF services. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for a skilled nursing facility admission. 
  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs or skilled therapy needs. 
The enrollees care needs can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair accessory, power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve the wheelchair accessory. You say that your leg is weak and having a seat 
elevator will help you a lot. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair accessory have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the wheelchair accessory, power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair with power 
options/features. 
 
You asked the Plan to pre-approve a group three power wheelchair with power options/features. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for 
the requested device. 
 
The Plan must follow Medicare rules. The rules say that the enrollee must be capable of safely operating the 
requested power mobility device. 
 
Review of the file shows does not support that you can safely operate a group three power wheelchair. 
Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair with power 
options/features.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmental pneumatic compression device (E0652, 
E0668). 
 
You asked the Plan to pre-approve a segmental pneumatic compression device. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0652, is covered for the treatment 
of lymphedema extending onto the chest, trunk and/or abdomen 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 a segmental pneumatic compression 
device. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on 
the medical records provided there is no documentation that the segmental pneumatic compression device at 
issue in this case meets Medicare/Local Coverage Determination (LCD): Pneumatic Compression Devices - 
L33829 criteria for medically reasonable and necessary. Provided records do not document trial and failure of 
four weeks of daily, multi-hour use of a basic pump after careful, in-person fitting, training and supervision by 
a technician who is skilled in and who regularly and successfully uses the device as required by the LCD. 
 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 segmental pneumatic compression device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a segmental pneumatic compression device (E0652, E0668).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that you are compliantly wearing the vent and 
records have been submitted to show necessity. The Plan denied your request. The Plan says the Plan says the 
request for a home mechanical ventilator set in PS (TgV) mode that could be delivered by BiPAP is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found provided records document chronic 
respiratory failure consequent to chronic obstructive pulmonary disease. There is no documentation that the 
portable ventilator at issue in this case meets Medicare criteria. As stated in the Local Coverage Determination 
(L33800), claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in 
this RAD policy will be denied as not 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 a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral lumbar medial branch blocks. 
 
You asked the Plan to pre-approve bilateral lumbar medial branch blocks. You say that bilateral lumbar medial 
branch blocks are medically necessary. The Plan denied your request. The Plan says bilateral lumbar medial 
branch blocks do not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 lumbar medial branch blocks. 
Our reviewer says that bilateral lumbar medial branch blocks are not medically necessary. Our physician 
reviewer found you failed 4-6 weeks of conservative treatment. The provider has requested 3-level bilateral L3-
4, L4-5, and L5-S1 facet joint injections, which correlates to medial branch blocks L3, L4, L5, and S1. The 
review has determined that the enrollee does not have a covered indication for the requested bilateral lumbar 
medial branch blocks as requested. 
 
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 lumbar medial branch blocks have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bilateral lumbar medial branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient visit to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve an outpatient visit to be provided by the requested out-of-network provider. 
The Plan denied your request. The Plan says the members health Plan only allows out-of-network care in the 
setting of an emergency, to preserve continuity of care, or when an in-network physician cannot provide the 
needed service. None of these scenarios apply to this members request. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an 
outpatient visit to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enfortumab (Padcev) (J9177) and Pembrolizumab 
(Keytruda) (J9271) to be used in combination. 
 
You asked the Plan to pre-approve Padcev and Keytruda. The Plan denied your request. The Plan says the 
National Comprehensive Cancer Network (NCCN) compendia does not support these medications being used 
in combination for the enrollee's cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Padcev and Keytruda. Our reviewer 
says that Padcev and Keytruda to be used in combination are not medically reasonable and necessary. Our 
physician reviewer found this regimen of Padcev and Keytruda is not compendia supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Padcev and Keytruda have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Enfortumab (Padcev) (J9177) and Pembrolizumab (Keytruda) (J9271) to be used 
in combination.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA). 
 
You asked the Plan to pre-approve a CTA. You say that the CTA is medically necessary. The Plan denied your 
request. The Plan says the procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CTA 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 a CTA. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee does not have chest pain or other 
cardiac symptoms. Clinical guidelines for the use of coronary CTA have not been met based on review of the 
submitted clinical documentation. As a result, at this time coronary CTA would not be considered medically 
reasonable and necessary in the enrollee's clinical management. 
 
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 CTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a computed tomographic angiography (CTA).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that it is medically necessary for the enrollee to get this 
injection. The Plan denied your request. The Plan says this request was denied as the medication is not being 
used for a medically accepted indication. 
 
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 Eylea. Our reviewer says that Eylea is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found Eylea is not FDA-
approved for treatment of neovascular glaucoma of the right eye with a vitreous hemorrhage. Treatment of 
neovascular glaucoma of the right eye with a vitreous hemorrhage with Eylea is not supported by one of the 
major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services 
approved medical journal. Our reviewer also found that treatment of neovascular glaucoma of the right eye 
with a vitreous hemorrhage with Eylea is not indicated, supported or recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Purewick urine collection system coded as K1006, 
A4328 and A5102. 
 
You asked the Plan to pre-approve the Purewick system. You say that you cannot get up and down to get to the 
restroom due to issues with your knees and a heart condition. The Plan denied your request. The Plan says the 
Purewick urine collection system is a convenience item and is not currently eligible for Medicare 
reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Purewick urine collection system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Purewick urine collection system coded as K1006, A4328 and A5102.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor (CGM) and 
supplies (K0553, K0554). 
 
You asked the Plan to pre-approve the CGM monitor and supplies. You say that the provided records should 
support the necessity of the requested service. The Plan denied your request. The Plan says the enrollee takes 
insulin twice per day and does not adjust insulin dose based on BG results and therefor does not meet Medicare 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM monitor and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor 
(CGM) and supplies (K0553, K0554).