Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 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 IRF admission and services.
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 enrollee requires an IRF to help them recover 
from surgery. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
the enrollee can receive the care they need in another setting. 
 
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 rehabilitation nursing or treatment by multiple therapies. 
Although they have had a functional decline from their baseline level of function and would benefit from 
occupational and physical therapy, the enrollee does not require the intensity of therapies provided in acute 
inpatient 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation does not support the rationale for this invasive imaging study. 
Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time cardiac 
catheterization would not be considered medically appropriate and necessary in this enrollees 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
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 IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The member 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 the member 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. The member 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a repeat epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, there is 
no documentation of a recent failure to respond to four weeks of noninvasive conservative care. The review has 
determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat epidural steroid injection.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilreta. 
 
You asked the Plan to pre-approve Zilretta. You say that you would like reconsideration because the requested 
drug is medically necessary. The Plan denied your request. The Plan says that repeat treatment with this drug is 
not indicated and the safety and efficacy of repeat administration has not been established. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that Zilretta 
is indicated as an intra-articular injection for the management of osteoarthritis pain of the knee. The product 
label does not preclude the use of this drug more than one time. Our physician reviewer found the 
documentation supports that Zilretta is medically reasonable and necessary for the enrollee, and that it is safe 
and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
Zilreta.  
 
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 pre-approve the consultation and treatment (CPT code(s): 37220, 
37221, 37224, 37225, 37226, 37227, 37228, 37229, and 37231). 
 
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 indication that you have a blockage that would be causing your discomfort or 
that would require treatment. The Plan states an arterial ultrasound performed in November 2021, also showed 
completely normal blood flow and a normal ankle brachial blood pressure test (ABI) of .93 on the left side and 
1.1 on the right side. The Plan states this test was also read as showing no arterial blockages. The Plan states 
your physician has also not tried to use a medication called cilostazol which can sometimes help with walking 
discomfort. 
 
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 documentation does not confirm the presence of severe disease, nor has there been a trial of 
medical therapy. In summary, there is insufficient documentation to support the medical necessity for lower 
extremity angiography and revascularization in your 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the consultation and treatment (CPT code(s): 37220, 37221, 37224, 37225, 37226, 37227, 
37228, 37229, and 37231).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear device implantation. 
 
You asked the Plan to pre-approve a cochlear device implantation. You say that a cochlear device implantation 
is not medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare NCD coverage criteria for a cochlear device implantation. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a cochlear device implantation. Our 
reviewer says that a cochlear device implantation is not medically necessary. Our physician reviewer found that 
the provided records do not document that the enrollee has bilateral hearing loss as required by the NCD.  
 
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 cochlear device implantation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a cochlear device implantation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the surgical services are necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in 
the setting of chronic low back pain, have not been demonstrated in the peer-reviewed literature. 
 
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 intracept procedure. 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept procedure (CPT code(s): 64628 and 64629).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional homecare physical therapy (PT) 
visits. 
 
You asked the Plan to pre-approve additional homecare PT visits. You say that the 8 visits are medically 
necessary. The Plan denied your request. The Plan says submitted clinical records indicate that you have had 12 
homecare physical therapy visits to help strengthen you and to teach you a home exercise program, after a 
surgery for a right shoulder fracture. The records show that you are currently medically stable. Your condition 
no longer requires the care of a skilled physical therapist. Therefore, medical necessity is not established and 
not met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional homecare PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found you have previously been treated with outpatient 
therapies and should be independent with a home exercise program. There is no documentation of a recent 
injury or decline in function. The additional therapy services are not an appropriate duration and frequency for 
treatment of your medical condition and therefore 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 additional homecare PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve eight (8) additional homecare physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires an LTACH 
admission for ongoing management of acute care needs. You say that the enrollee is medically stable to be 
transferred to an LTACH and due to their medical conditions, they are unable to receive care in a lower level. 
The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee 
can receive the care they need in current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is unstable and requires short-term additional acute care services that can 
be safely provided at the current facility until they are stable enough for transfer. The enrollee does not require 
services at the LTACH that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) 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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lumbar spinal surgery. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can tolerate 15 hours a week of 
interdisciplinary physical and occupational therapy. The Plan denied your request. The Plan says based on the 
available clinical information, we have determined the enrollee's status does not meet medical necessity 
severity or intensity 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 the enrollee's nursing medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesn't support that she would meet criteria for admission to an 
acute rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an 
IRF, participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 
3 visits weekly to regain or maintain her functional status. The enrollee 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 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 service. You say that the service is necessary. The Plan denied your 
request. The Plan says there is little evidence in the medical literature to suggest that this is an appropriate 
procedure for your back pain. 
 
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 service. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept 
procedure (CPT code 64628).