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 intensive physical therapy is needed to even hold 
your head up. You also say that without therapy, you could be bed ridden forever. The Plan denied your 
request. The Plan says based on Medicare guidelines, the IRF services being 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 while you may benefit from continued physical therapy, speech therapy, and 
occupational therapy, your rehabilitation needs can be safely provided in a lower intensity and alternate setting 
such as in a skilled nursing facility (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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical, (E0747). 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that the documentation supports the 
enrollee has a non-union fracture post 90-days. The Plan denied your request. The Plan says your records do 
not show x-rays at least ninety days apart showing no healing of the broken bone. 
 
The Plan follows Medicare rules. Medicare rules say that a non-spinal electrical osteogenesis stimulator is 
covered only if the 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 an osteogenesis stimulator. Our 
reviewer says that the requested osteogenesis stimulator does not meet the criteria for coverage. Our physician 
reviewer found the provided records do not document non-union of a long bone fracture, defined as 
radiographic evidence that fracture healing has ceased for three or more months prior to starting treatment with 
the osteogenesis stimulator. Therefore, the reviewer found that the criteria for coverage have not been met.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator, electrical, (E0747).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that 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 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee does require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a 
week, or 15 hours over seven consecutive days. The enrollee has had a functional decline from his baseline 
level of function and would benefit from the intensity of therapies provided on acute inpatient rehabilitation. 
Therefore, the acute inpatient rehabilitation admission is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a creatine deficiency syndromes panel (genetic test) 
(81479). 
 
You asked the Plan to pre-approve genetic testing. You say that your doctor says this test is medically 
necessary. The Plan denied your request. The Plan says the provided documentation fails to indicate how the 
individual test results of this panel would impact your care. Therefore, the medical necessity criteria for this 
testing are not 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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided documentation does not show how the individual test results would change 
your treatment. Therefore, the items/services at issue in this case are 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a creatine deficiency syndromes panel (genetic test) (81479).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve a power wheelchair. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the records do not indicate that the enrollee had a home evaluation to 
evaluate whether the enrollee's home provides adequate access between rooms, maneuvering space, and 
surfaces for the operation of the power vehicle. 
 
The Plan must follow Medicare rules. Medicare rules say that a POV can be covered only if the beneficiarys 
home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV 
that is provided.  
 
We looked at the file and Medicare rules. The file does not indicate the enrollee has had a home evaluation 
confirming the beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces 
for the operation of the POV that is provided. Based on this information, we decided that Medicare rules for 
coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power wheelchair 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 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 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 has chronic functional impairment and has declined following two acute hospital stays. She does not have complex or intensive rehabilitation needs and does not require frequent 
physiatry oversight. Her most recent stroke was in March more than 6 months ago. She has no barriers to 
recovery with standard rehabilitation care provided at a level of care other than the IRF. Criteria are not met. 
 
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 fifteen (15) fractions of proton beam therapy, image 
guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is no current research showing that the enrollee's type of cancer will respond better 
to this treatment; therefore, this treatment is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. 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 current research showing that the enrollee's type of cancer will respond better to this 
treatment. There is insufficient prospective, long-term clinical data available to determine whether or not 
proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation 
therapy, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve fifteen (15) fractions of proton beam therapy, image guided radiation therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide (E1399). 
 
You asked the Plan to pre-approve a stair glide. You say that your mother was approved for a stair lift from her 
physician. You say there should be no dispute that the request was transmitted. The Plan denied your request. 
The Plan says your request is not a covered benefit because a stair lift is not primarily and 
customarily used to serve a medical purpose and is generally useful to a person in the absence of illness or 
injury. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro orthosis. 
 
You asked the Plan to pre-approve MyoPro orthosis. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MyoPro orthosis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of a stroke with left-sided weakness. Based on the medical 
records provided there is no documentation that the MyoPro Orthosis at issue in this case meets Medicare 
criteria for medically reasonable and necessary. Current clinical guidelines designate robotic therapy to be of 
"uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven 
benefit in the home environment. Although records from the device manufacturer/vendor argue medical 
necessity of the requested device, records from the enrollee's actual treating provider do not fully clarify why 
the requested device is the most appropriate treatment for the enrollee's condition. In addition, provided records 
report left upper extremity shoulder subluxation and left upper extremity spasticity which may be a contraindication to use of the device. Therefore, the enrollee does not meet 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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve MyoPro orthosis.
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 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 have intensive rehabilitation needs. She is able to ambulate in 
her room without assistance. She is able to receive medically necessary rehabilitation services at a level of care that does not require an IRF admission. There is no indication for frequent physiatry oversight. The wound care 
does not require an IRF admission. 
 
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 home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested ventilator is to be used for the 
treatment of possible COPD, post-COVID pneumonia and failure to thrive. The Plan denied your request. The 
Plan says the request for a home mechanical ventilator set in AVAPS mode with Auto-EPAP (AE) 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you appear to have chronic 
hypercarbic respiratory failure based on ABGs done while acutely ill. The etiology for the respiratory failure 
appears to be multifactorial, including severe malnutrition, CHF, and mental status changes.  There is no data 
to support a diagnosis of COPD, and there is no thoracic restrictive disease or neuromuscular disease. You may 
benefit from BiPAP with AVAPS and backup rate during sleep. This has not been tried as an outpatient.  
Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
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 is medically stable and does not need a physician's supervision three 
times a week in an IRF.  No acute rehabilitation nursing needs are identified or documented. There are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3030). 
 
You asked the Plan to pre-approve foot orthotics. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3030).
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 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 is mildly deconditioned following an acute stay. He is functioning at a 
level that does not require intensive rehabilitation. He has access to rehabilitation services that will provide recovery without admission to the IRF. He does not have complex rehabilitation needs requiring frequent 
physiatry oversight. 
 
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 office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network Podiatry 
specialists that can provide the care and treatment you are requesting. 
 
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 
office visits to be provided by an out-of-network (OON) provider.