Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external infusion pump (E0784). 
 
You asked the Plan to pre-approve an external infusion pump. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section must 
be met for coverage. 
 
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 external infusion pump. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the c-peptide is greater 
than 200% of the lower limit of normal of the lab normal range and there is also no simultaneous fasting 
glucose provided. 
 
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 external infusion pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external infusion pump (E0784).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gradient compression wrap (CPT code A6545). 
 
You asked the Plan to pre-approve the gradient compression wrap. You say that the gradient compression 
wraps are needed to prevent increase ulcerations. The Plan denied your request. The Plan says this type of 
compressive wrap will only be approved as a primary or secondary dressing for wounds caused by a surgical 
procedure, or for those which have had a surgical debridement. The Plan states the enrollee's wound does not 
qualify for coverage of this request due to the statutory requirements, and on the left side, there is no wound. 
 
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 gradient compression wrap. Our 
physician reviewer found no surgery was recently completed or planned for future. There was also no wound 
documented on the left side. A request for gradient compression wraps (both legs) was made for prevention of 
ulcerations. Based on the facts that the enrollee did not have a wound that required surgery or had recently 
received surgery, and that there is no wound on the left side does not sufficiently meet Medicare coverage 
criteria. 
 
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 gradient compression wrap have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the gradient compression wrap (CPT code A6545).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you need the SNF services because you 
are very weak and are a great fall risk. The Plan denied your request. The Plan says the SNF services you are 
requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-
approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, 
including programming (CPT code 33285). 
 
You asked the Plan to pre-approve the services. You say that an implanted loop recorder (ILR) is needed, since 
arrhythmia and symptoms have not clearly been occurring frequently enough for external monitor to reliably 
detect the problem. The Plan denied your request. The Plan says the requested services are not reasonable and 
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 the services. Our physician reviewer 
found at issue is whether the requested authorization for placement of an ILR is medically appropriate and 
necessary. There is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke 
or any other apparent indication for an ILR. In summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this patients 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 insertion, subcutaneous cardiac rhythm monitor, including programming (CPT code 
33285).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography of the heart without contrast, with a 
quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve computed tomography of the heart without contrast, with a quantitative 
evaluation of coronary calcium. The Plan denied your request. The Plan says that the enrollee does not meet the 
Medicare criteria. The Plan says records show that the enrollee may have a disease caused by plaque buildup in 
the walls of the blood vessels (atherosclerotic cardiovascular disease). 
 
The Plan follows Medicare rules. Medicare rules say that CTA is a general phrase used to describe a non-
invasive method, using intravenous contrast, to visualize the coronary arteries (or other vessels) using high-
resolution, high- speed CT. Medicare rules say that if there are no specific coverage rules for an item or 
service, then that item or service will be covered when it is 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 computed tomography of the heart 
without contrast, with a quantitative evaluation of coronary calcium. Our reviewer says that a computed 
tomography of the heart without contrast, with a quantitative evaluation of coronary calcium is medically 
reasonable and necessary. Our physician reviewer found that despite a negative nuclear medicine stress test in 
2020 the enrollee experiences left parasternal intermittent chest pain, has a very strong family history of 
atherosclerotic cardiovascular disease (ASCVD) and has chronic obstructive pulmonary disease (COPD) due to 
occupational exposure. He has well controlled hypertension. Due to the atypical chest pain and strong family 
history of ASCVD a coronary calcium scoring CT is a reasonable test and should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computed tomography of the heart without contrast, with a quantitative 
evaluation of coronary calcium have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography of the heart without contrast, with a quantitative evaluation of coronary calcium.  
 
 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 pay for the inpatient mental health services provided from 
September 24, 2021, to September 28, 2021. 
 You asked the Plan to pay for the inpatient mental health services. You say that you would like this claim to be 
reconsidered for coverage. The Plan denied your request. The Plan says this claim processed and denied 
correctly. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient mental health services. Our 
reviewer says that the enrollee did not meet the Medicare criteria for inpatient psychiatric care. Our physician 
reviewer found that it was not expected this enrollee would improve in a reasonable period of time as he did 
not have dangerousness to themself or others, auditory or visual hallucinations, or aggressive behaviors. Our 
reviewer found that the enrollee was cooperative and compliant with treatment. Our physician reviewer also 
found that the records provided for the admission of this patient does not meet criteria for acute inpatient 
mental health treatment. 
 
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 inpatient mental health services have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient mental health services provided from September 24, 2021, 
to September 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care services. 
 
You asked the Plan to pre-approve SNF services. You say that you need SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found at the time of admission into the nursing 
facility, you were medically stable. You did not require any skilled nursing or rehab services on a daily basis at 
an inpatient level of care.  You were not expected to make measurable gains within a reasonable and 
predictable period of time or require skilled therapy to prevent deterioration with mobility or self-care tasks.  
You did not require skilled therapy to establish a safe and effective maintenance program.  As a practical 
matter, you did not require any skilled services on an inpatient basis, at a SNF level of care at the time of 
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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care 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 therapy and rehabilitation are essential in your 
journey to gain back mobility. You also say that therapy is recommended by your doctor after surgery. The 
Plan denied your request. The Plan says the IRF admission 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 the provided documentation does not indicate that you have complex nursing or 
rehabilitation needs. The reviewer found that while you have a need for therapy, there is no documentation of a 
need for an intensive rehabilitation program. The reviewer also found that there is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Therefore, the reviewer found that the requested IRF admission is 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 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 continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found The medical record is reviewed in its entirety. 
You have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing 
and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services 
at a lower level of care. Although further rehab services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 continuous glucose monitoring 
sensor. 
 
You asked the Plan to pre-approve the continuous glucose monitoring sensor. You say that you had a stroke 2 
years ago and has not been able to test your blood sugar for 2 months. The Plan denied your request. The Plan 
says the enrollee is not receiving insulin shots or using an insulin pump and does not meet the Medicare 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitoring sensor have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 2 continuous 
glucose monitoring sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power upper extremity range of motion assist device, 
elbow, wrist, hand, finger. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the device falls into the class of experimental and unproven. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert 
opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 a power upper extremity range of motion assist device, elbow, wrist, hand, finger.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve office visit services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there are in-network options for your medical care available to choose from. 
 
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 visit services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm (J0172). 
 
You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use is not supported. 
 
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 Aduhelm. Our reviewer says that the 
requested use of Aduhelm is not supported. Our physician reviewer found Aduhelm is FDA-approved for the 
treatment of Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease. 
The case file dose not contain documentation of a Mini-Mental State Examination (MMSE). The 
documentation does not support that Aduhelm is at least as beneficial as existing and appropriate and available 
medically appropriate alternatives for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aduhelm (J0172).