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 need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee 
may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be safely met in an 
alternate and lower intensity setting such as in a skilled nursing 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.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a pelvic Magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve a pelvic MRI. You say that the requested pelvic MRI is medically 
necessary. The Plan denied your request. The Plan says that the requested pelvic MRI is not medically 
necessary. 
 
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 a pelvic MRI. Our reviewer says that 
the requested pelvic MRI is medically necessary. Our physician reviewer found in this case the information 
provided for review suggests that the member has pelvic and low back pain. The member underwent MRI of 
the lumbar spine which did not find a causative etiology for her pain. 
 
In such a context, imaging of the pelvis would be reasonable and necessary to look for other etiologies of groin 
pain (e.g., plexopathy, mass, soft tissue condition). As Medicare (per the applicable NCD) covers MRI studies 
when they are reasonable and necessary, this service would otherwise be eligible for coverage 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 a pelvic MRI have been met. Therefore, we decided that the Plan has to pre-
approve a pelvic Magnetic resonance imaging (MRI).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on August 11, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says payment cannot be made to providers who are not eligible to accept 
Medicare payment structures. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made for services 
provided by a physician or practitioner who is not a Medical eligible provider. The services at issue in this 
appeal were provided by a physician who has opted out of the Medicare program. Therefore, we decided that 
the Plan does not have to pay for physician services provided on August 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not require any skilled nursing 
services. It is not medically reasonable and necessary to provide skilled therapy services on a daily basis on an 
inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sacroiliac joint injection. 
 
You asked the Plan to pre-approve the sacroiliac joint injection. The Plan denied your request. The Plan says 
the 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 the sacroiliac joint injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the records provided do not establish the medical necessity and 
reasonableness of the requested service as defined by Medicare rules. Therefore, the elements of the coverage 
criteria are not satisfied, and the requested service is not recommended. 
 
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 sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the sacroiliac joint injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that a family member seen this provider 
prior, and the service was exceptional. The Plan denied your request. The Plan says a list of in-network 
providers was given to the enrollee that provide the same service. 
 
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 
physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable sensors for a continuous glucose monitor 
(CGM). 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that codes A9276 and A9277 are not used to bill for 
supplies used with code K0554. 
 
We looked at the file and Medicare rules. The services at issue are sensors described by code A9276. This code 
is for non-therapeutic CGMs and the sensors are therefore not covered. Therefore, we decided that the Plan 
does not have to pre-approve disposable sensors for a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve these services. You say that you need the elevated lift due to being a double 
amputee. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) is non-covered. 
 
We looked at the file and Medicare rules. The item at issue is a power seat elevation system. This item is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation 
system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve the guided tissue regeneration. The Plan denied your request. The Plan says 
this service is not covered under the enrollee's benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
guided tissue regeneration (D4266).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter coded as E0118. 
 
You asked the Plan to pre-approve the knee scooter. You say that you do not agree with this denial because you 
need to be off your feet for 2 weeks and cannot do this with a crutch. You will not have any mobility without 
this device. The Plan denied your request. The Plan says this is not an item which can be covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare contractors have determined that the 
items described by E0118 are not considered reasonable and necessary for the Medicare population.  
 
Although this device may be appropriate, no coverage is available for this from Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pre-approve a knee scooter coded as E0118.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an enclosed frame walker (E0144). 
 
You asked the Plan to pre-approve the walker. You say that you are unable to walk without a walker. The Plan 
denied your request. The Plan says a face-to-face Periscope evaluation is needed prior to approval of a walker. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical necessity for a walker with an 
enclosed frame (E0144) has not been established. 
 
The medical necessity of the specific walker requested is not established at this time. Based on this 
information, we decided that Medicare rules for coverage of the walker have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an enclosed frame walker (E0144).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mobile cardiac outpatient telemetry (MCOT) monitor. 
 
You asked the Plan to pre-approve MCOT monitor. You say that you need to keep an eye on the enrollee's 
heart rate. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that cardiac event detection may be covered under 
certain circumstances. 
 
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 MCOT monitor. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested MCOT monitor. Our physician reviewer found there is no supportive evidence that the ordering practitioner documented any standard, non-MCOT, 
ambulatory electrocardiogram (EKG) monitoring. There is insufficient documentation to support the medical 
necessity for this MCOT monitoring 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 MCOT monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve mobile cardiac outpatient telemetry (MCOT) monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
need a team of providers. 
 
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 physician reviewer found 
that the enrollee does not require the intensity of services provided at an IRF. Specifically, she is not shown to 
be able to tolerate fifteen hours per week of rehabilitative services or to require regular physician evaluation. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the eye surgery. You say that you need the eye surgery. The Plan denied 
your request. The Plan says a list of in-network providers was given to the enrollee that provide the same 
service. 
 
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 eye surgery to be provided by an out-of-network (OON) provider.
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's current medical condition does not require intensive physician or 
nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but 
the documentation does not reveal that this therapy must be only on an intensive level 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous immuneglobulin (IVIG) therapy rendered on 
June 30, 2021 to July 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that IVIG 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found there is no documented evidence of rapid 
progression of a covered disease or relapse or that other forms of treatment had failed or were contraindicated. 
There is no physician documentation of the rationale for the choice of therapy considering the disease activity. 
The IVIG was 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 pay for the intravenous immuneglobulin (IVIG) therapy rendered on June 30, 2021 to July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gradient compression stockings (CPT code A6533 
x8), for the enrollee. 
 
You asked the Plan to pre-approve the gradient compression stockings. You say that the enrollee was seen in 
the office and diagnosed with a deep vein thrombosis of your right lower extremity. You state the standard of 
care for this is to use compression stockings and blood thinning medication such as Eliquis. The Plan denied 
your request. The Plan says this item is not covered by Medicare of this health plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The rules say that the 
following are examples of wound care items which are non-covered under the surgical dressing benefit because 
they do not meet the statutory definition of a dressing (not all-inclusive): Gradient compression stockings 
(A6533). Based on this information, we decided that Medicare rules for coverage of the gradient compression 
stockings have not been met. Therefore, we decided that the Plan does not have to pre-approve the gradient 
compression stockings (CPT code A6533 x8), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your new baseline and you can 
receive 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single photon emission computed tomography 
(SPECT) test. 
 
You asked the Plan to pre-approve SPECT. You say that the enrollee has multiple issues that need evaluation. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
enrollee does not have electrocardiogram (EKG) findings that could make it hard to determine whether the 
heart is getting enough blood supply, or an inability to walk on a treatment, or abnormal test results that do not 
appear to be due to coronary artery disease. 
 
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 SPECT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee's pre-test probability for an abnormal test is low and electrocardiogram (EKG) 
shows an interpretable pattern. There is no evidence provided that would support the need for radionuclide 
stress testing. In summary, there is insufficient documentation to support the necessity for the requested cardiac stress testing in this 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 SPECT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a single photon emission computed tomography (SPECT) test.