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 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 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 you do not have an IRF compliant diagnosis. Additionally, there are no active 
medical conditions or hospital complications that would require continued inpatient hospitalization during 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation discharge services provided on October 26, 
2021, billed with code 99217. 
 
You asked the Plan to pay for the observation discharge services. You say that this provider rendered these 
services and should be paid. The Plan denied your request. The Plan says there was no claim submitted for 
initial observation care for this enrollee. Observation discharge cannot be paid if initial observation care was 
not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for observation discharge can be made 
if observation initial care is also provided.  
 
We looked at the file and Medicare rules. The Plan has indicated that no provider billed or was paid for initial 
observation care in the code range 99218-99220. Based on this information, we decided that Medicare rules for 
coverage of the observation discharge services have not been met. Therefore, we decided that the Plan does not 
have to pay for the observation discharge services provided on October 26, 2021, billed with code 99217.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits, 8 home health 
physical therapy visits, and 3 home health occupational therapy visits. 
 
You asked the Plan to pre-approve 3 home health skilled nursing visits, 8 home health physical therapy visits, 
and 3 home health occupational therapy visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 3 home health skilled nursing visits, 8 
home health physical therapy visits, and 3 home health occupational therapy visits. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the documentation does not 
support that the enrollee requires additional skilled nursing services or skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing or rehabilitation 
services to effectively provide treatment, care, and/or services in order to improve the enrollees condition, 
perform a maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee 
has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
The requested home health services are not 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 3 home health skilled nursing visits, 8 home health physical therapy visits, and 
3 home health occupational therapy visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 3 home health skilled nursing visits, 8 home health physical therapy visits, and 3 home health 
occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that the requested sacroiliac joint 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the sacroiliac joint injection. 
 
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 a sacroiliac joint injection. Our 
reviewer says that the enrollee does not meet criteria for the sacroiliac joint injection. Our physician reviewer 
found in this case, the member is not achieving significant pain relief for at least 6 weeks, and discussion of 
nerve ablation treatment has not been documented. The review has determined that the enrollee does not meet 
the LCD criteria for the requested sacroiliac joint injection. 
 
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 sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nasal valve and laser surgery of the inside of the nose. 
 
You asked the Plan to pre-approve nasal valve and laser surgery of the inside of the nose. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have 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 nasal valve and laser surgery of the 
inside of the nose. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is insufficient evidence in the medical literature 
to support that nasal valve and laser surgery inside the nose is medically reasonable and necessary for the 
enrollee in this case. The long-term results of the proposed surgeries, and how they compare to other treatment 
regimens has not been determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nasal valve and laser surgery of the inside of the nose have not been met. 
Therefore, we decided that the Plan does not have to pre-approve nasal valve and laser surgery of the inside of 
the nose.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi electric hospital bed and lift. 
 
You asked the Plan to pre-approve a semi electric hospital bed and lift. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
items. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
2. Requires attachments which can only be attached to a hospital bed; AND 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi electric hospital bed and lift. Our 
reviewer says that the documentation does not support that the requested items are medically reasonable or 
necessary. Our physician reviewer found the enrollee has a diagnosis/medical history of cardiovascular disease 
and heart failure. The documentation does not support that the enrollee's condition requires position of the body 
in ways not feasible in an ordinary bed. The provided records do not support that transfer between bed and a 
chair, wheelchair, or commode is required and, without the use of a lift, the enrollee would be bed confined. 
The enrollee is reported to be minimum to moderate assist with sit to stand transfers. The therapy notes report 
the enrollee uses a lift device for stairs but not for bed to chair transfers. Therefore, the enrollee does not meet 
criteria for the requested semi electric hospital bed or lift. 
 
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 semi electric hospital bed and lift have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a semi electric hospital bed and lift.
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 the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the home ventilator. Our reviewer says 
that the ventilator is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee was successfully treated with BiPAP while in the hospital and was planned to be continued once 
discharged. The enrollee's needs can be met with a BiPAP machine. 
 
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 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 with your fracture you remain de-conditioned, and 
you are getting weaker. The Plan denied your request. The Plan says the request is not medically necessary, the 
services you need can be provided safely in other settings. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the 30-day dispensing fee for drug provided on March 30, 2022, billed 
with code Q0513. 
 
You asked the Plan to pay for the billed code Q0513. You say that this is a payable code for medically 
necessary supplies that were approved. The Plan denied your request. The Plan says that there is no fee for this 
code under the Michigan Medicare contractor. Therefore, no payment can be made for this. 
 
The Plan must follow Medicare rules. Medicare rules say that after an enrollee has had the initial dispensing fee 
covered under code G0333, subsequent claims for the 30-day dispensing fee are reported and paid under code 
Q0513. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the billed code Q0513 have been met. Specifically, this is a covered code the fee for which is set 
by the Durable Medical Equipment (DME) contractor, not the Medicare Part B contractor. We have confirmed 
that the fee for this code is available on the DME contractor website. Therefore, we decided that the Plan has to 
pay for the 30-day dispensing fee for drug provided on March 30, 2022, billed with code Q0513.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the therapy staff continues to recommend acute care. 
The enrollee has stairs at home and is not able to safely navigate those. The Plan denied your request. The Plan 
says the enrollee does not meet the Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 clinical documentation shows the enrollee has functional impairments however 
evaluating therapists do not show that they would tolerate or require intense therapy. There is no specific 
mention of any complex conditions that would require a multi-disciplinary approach to 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 IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Infed and Venofer. 
 
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 Injectafer. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrolleee has tried and failed the preferred drugs. The reviewer found that there is no 
documentation provided indicating that the plans required drug(s) would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rosuvastatin tablets. 
 
You asked the Plan to pre-approve Rosuvastatin tablets. The Plan denied your request. The Plan says 
Rosuvastatin tablet is a self-administered drug, and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rosuvastatin tablets.  
 
Benefits for Rosuvastatin tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a nerve stimulator (63650). 
 
You asked the Plan to pre-approve the nerve stimulator. You say that the stimulator is medically necessary. The 
Plan denied your request. The Plan says that sufficient conservative therapy has not been tried. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is covered to treat intractable 
pain caused by nerve root injuries, post-surgical or post-traumatic including that of post-laminectomy 
syndrome (failed back syndrome). 
 
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 nerve stimulator. Our reviewer says 
that the requested spinal cord stimulator is medically necessary. Our physician reviewer found the health plan 
states the enrollee has not trialed conservative therapy. The patient is unable to exercise due to pain and has a 
very high Owestry score. She had a course of Physical therapy in the past. The enrollee has psychological 
evaluation and clearance. 
 
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 nerve stimulator have been met. Therefore, we decided that the Plan has to 
pre-approve a nerve stimulator (63650).  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is not medically necessary. The Plan denied 
your request. The Plan says that the coverage 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 that the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services and 
regular physician evaluation. The enrollees care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the OneTouch Ultra test strips. 
 
You asked the Plan to pre-approve the OneTouch Ultra test strips. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is no medical need for the requested strip over the Plan's 
preferred brand. 
 
The Plan follows Medicare rules. Medicare rules say that the Plan may specify certain brands as preferred as 
long as criteria listed in the Medicare rules section 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 the OneTouch Ultra test strips. Our 
reviewer says that the requested brand of test strips is not medically necessary over the Plan's preferred brand. 
Our physician reviewer found there is no mention of why the enrollee needs the OneTouch Ultra test strips 
rather than the FreeStyle strips which is the Plan's preferred brand. 
 
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 OneTouch Ultra test strips have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the OneTouch Ultra test strips.