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 you feel that intensive therapy is necessary for you. 
The Plan denied your request. The Plan says your needs can be met in the nursing facility level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 was admitted to the hospital due to cerebellar strokes. As of September 
19, 2022, the enrollee requires contact guard assistance to ambulate to the bathroom and transfer in and out of the shower.  
 
The enrollee is functioning at a level that responds to repetitive exercise and does not require daily skilled 
therapy to restore or maintain function. He does not have complex 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: 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 this individual 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare due to insufficient evidence of efficacy. 
 
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 the intracept procedure is experimental. More research is needed. 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 the intracept 
procedure (CPT code 64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not have a medically necessary indication. 
 
The Plan follows Medicare rules. Medicare rules say that electrical nerve stimulators are only covered under 
certain medical indications.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has chronic abdominal and low back pain, the etiology of which is unclear.  
The enrollee's pain has been unresponsive to treatment with narcotic pain medication, acupuncture and a home 
exercise program. Magnetic resonance imaging (MRI) of the thoracic spine does not show a surgical issue. The 
records do not include any imaging (x-rays, MRI, CT scan) of the lower back. Therefore, the cause and 
possible alternative treatments for the enrollee's low back pain are unknown at this time. The enrollee has been 
deemed not to be a surgical candidate for the abdominal pain. The records also do not indicate that the enrollee 
has been evaluated by a spine surgeon for the low back pain or evaluated to determine if the enrollee is a 
suitable candidate for a spinal cord stimulator. Therefore, this service is not considered to be reasonable and 
necessary under Medicare. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the requested services. You say that the pain is affecting your quality of life. 
The Plan denied your request. The Plan says the service is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage for any 
service, the information must corroborate the documentation in the beneficiary's medical documentation and 
confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. In this case, there are no medical records to show that the requested 
services are medically necessary. Therefore, we decided that the Plan does not have to pre-approve 
radiofrequency ablation of the sacroiliac joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have diabetes and cannot stand too long. 
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 shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require or can tolerate this therapy on an intensive IRF level. Therapy notes indicate you are limited in therapy 
by fatigue. 
 
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 computed tomographic (CT) colonography, screening, including 
image postprocessing (74263). 
 
You asked the Plan to pre-approve a CT colonography. You say that this procedure will address the enrollee's 
condition of diverticulosis of sigmoid colon. The Plan denied your request. The Plan says that the requested 
procedure does not meet criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT colonography. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the rules say that CT scans are covered if 
there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the 
patient. In this case, the record indicates that the enrollee had an incomplete colonoscopy in March 2022 due to 
severe diverticulosis. The record indicates the presence of polyps. The requested test is not screening in nature. 
The provided records are sufficient to establish the medical necessity or reasonableness, as defined by 
Medicare rules, of the requested service.  The elements of the coverage criteria are satisfied. The requested 
service is 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 a CT colonography have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomographic (CT) colonography, screening, including image postprocessing (74263).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a static or dynamic ankle foot orthosis (L4397). 
 
You asked the Plan to pre-approve a static or dynamic ankle foot orthosis. You say that the doctor ordered the 
requested orthotic for you and the Plan should cover it. The Plan denied your request. The Plan says the records 
show you have a sprain. You do not meet approval for the requested item. 
 
Medicare rules say the static or dynamic positioning ankle-foot is covered if all criteria are met. The Plan 
follows these same rules.   
 
Records show that you do not have one of the five listed diagnosis that support medical necessity for the 
requested ankle-foot orthosis. 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 a static or dynamic ankle foot orthosis (L4397).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide non-emergent transportation services. 
 
You asked the Plan to provide transportation. You say that you were recently diagnosed with cancer, and you 
need this transportation as you have no family in the area to help you. The Plan denied your request. The Plan 
says you do not qualify for this benefit as you have not requested a referral following a discharge from the 
hospital or a skilled nursing facility. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation only as part of a 30-day post-discharge benefit. In order to be 
eligible for this benefit, you mut have been discharged from a hospital or skilled nursing facility and have 
requested and received a referral for this benefit from the Plan.  
 
We looked at your request, the records in the case file, and the rules. The records do not show that you had 
been recently discharged from an eligible facility or that you have received a referral for this benefit from the 
Plan. Without this benefit referral, these services are not covered. Based on this information, we decided that 
the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan 
does not have to provide non-emergent transportation services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fifty-one (51) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have ongoing 
dialysis appointments every Tuesday, Thursday, and Saturday. You are requesting the additional trips since you 
have no transportation. The Plan denied your request. The Plan says you have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve fifty-one (51) additional routine transportation trips 
(A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that the requested Minuteman procedure 
is medically necessary. The Plan denied your request. The Plan says the requested Minuteman procedure 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 Minuteman procedure. Our 
reviewer says that the requested Minuteman procedure is not medically necessary. Our physician reviewer 
found the Minuteman procedure is experimental. More research is needed. At this time the procedure is 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 the Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing. 
 
You asked the Plan to pre-approve private duty nursing. You say that the services are necessary. The Plan 
denied your request. The Plan says the requested service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of private duty nursing have not been met. Therefore, we decided that the Plan does not have to pre-
approve private duty nursing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there 
was no documentation of conservative treatments. 
 
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 requested services. Our physician 
reviewer found that there is no documentation of physical therapy for low back pain. More conservative 
measures are needed. Therefore, the request is not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar fusion services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the 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 clinical documentation shows that the enrollee has multiple comorbidities however there is no listed IRF compliant admission diagnosis and there is no documentation as to why the enrollee 
would continue to require inpatient hospitalization with close physician supervision in an IRF. Additionally, 
evaluating therapists recommend less intense therapy in a skilled nursing facility. Thus IRF criteria have not 
been met and is 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 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 backup push wheelchair. 
 
You asked the Plan to pre-approve the backup push wheelchair. You say that you need the backup push 
wheelchair with power assist feature because it is getting too hard on you to get around with the wheelchair that 
you have. You say that you are going to have surgery on both shoulders. The Plan denied your request. The 
Plan says the item being requested is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The rules also say that backup chairs will be denied as not reasonable and necessary. 
 
 
 
 
 
 
 The file shows that you have a wheelchair. The requested backup push wheelchair serves the same purpose as 
the wheelchair you currently have. Backup chairs are not considered reasonable and necessary. Therefore, we 
decided that the Plan does not have to pre-approve a backup push wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiaflex (J0775). 
 
You asked the Plan to pre-approve Xiaflex. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by their Medicare Part B plan. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Xiaflex (J0775).  
 
Benefits for Xiaflex may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.