Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you feel the skilled nursing facility is not 
able to do what needs to be done. The Plan denied your request. The Plan says based on Medicare guidelines 
the long term acute care hospital services you are requesting do not meet the requirements for approval. 
 
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 you are currently undergoing treatment at an acute care hospital for a post-operative 
shoulder infection. You are to receive a prolonged course of antibiotics. There is no evidence that you require 
services that are not currently available. You can remain at the current acute care hospital facility until such 
time no acute services are required and then can be transferred/discharged to a lower level of care for any 
ongoing long term care needs. 
 
 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 the LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Paclitaxel protein-bound. 
 
You asked the Plan to pre-approve Paclitaxel protein-bound. 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. 
 
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 Paclitaxel protein-bound. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Paclitaxel protein-bound have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Paclitaxel protein-bound.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found provided medical 
records document this enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. Provided records document that the home ventilator is being requested for use in average 
volume assured pressure support (AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for 
ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be 
denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4657 provided to the enrollee from January 
14, 2022, to January 14, 2022, to January 17, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code has a Medically Unlikely Edits (MUE) value of zero. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code A4657 is "Syringe, with or without needle, each." 
 
We find that procedure code A4657 is not supported in the medical record. Specifically, this code has a MUE 
value of 0, which means that it is improper to report the code. 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 pay for procedure code A4657 provided to the enrollee from January 14, 2022, to January 14, 2022, to 
January 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy, per session (99183) and 
hyperbaric oxygen under pressure, full body chamber, per 30-minute interval (G0277). 
 You asked the Plan to pre-approve the therapy services. You say that the enrollee has lost most of the hearing 
in their right ear and provider is trying to save what is left. The Plan denied your request. The Plan says based 
on Medicare guidelines, the oxygen treatment coded as physician attendance and supervision of hyperbaric 
oxygen therapy, per session (99183) x 20 and hyperbaric oxygen under pressure, full body chamber, per 30-
minute interval (G0277) x 80 - you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that HBO therapy is subject to the criteria listed 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 the therapy services. Our physician 
reviewer found the enrollee does not meet the requirements for hyperbaric oxygen therapy as she does not have 
a covered condition. Our physician reviewer also found that hearing loss is not listed as a covered condition in 
the Medicare rules. Therefore, hyperbaric oxygen therapy is not medically necessary 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve hyperbaric oxygen therapy, per session (99183) and hyperbaric oxygen under 
pressure, full body chamber, per 30-minute interval (G0277).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you still need skilled nursing services for your 
wounds. The Plan denied your request. The Plan says that the continued admission to a SNF is not medically 
necessary. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that you have multiple conditions that 
make you eligible for the injection. You say that you have fusion in your neck, which never healed properly 
due to diabetes and your back is hunched and pulls on your neck and shoulders. You say that you have stage 3 
kidney failure and arthritis in all of your spine and neck and you have bone spurs in your neck and sciatic nerve 
pain and there is no way you could go to a chiropractor because your neck is fused. The Plan denied your 
request. The Plan says the Plan did not receive any physical therapy or chiropractic therapy notes to show the 
member's inability to tolerate noninvasive conservative care or medical documentation of failure to respond to 
4 weeks of noninvasive conservative care. It is required to have tried at least 4 weeks of noninvasive 
conservative care before an injection would be approved. Additionally, member had a cervical epidural steroid 
injection on 8/5/2022 and reported 80% pain relief. A repeat epidural steroid injection is only indicated when 
one experiences 50% pain relief that lasts for at least 3 months. 
 
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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary in this case. Our physician reviewer 
found that the physical modalities of physical therapy or chiropractic for cervical radiculopathy (physical 
therapy has not occurred) and an ongoing home exercise and strengthening/conditioning program for cervical 
radiculopathy are not documented. A repeat ESI when the first injection directly and significantly provided 
improvement of the condition being treated may be considered medically reasonable and necessary when the 
medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using the same scale for at least three months. There is again, no clear documentation 
of this having been achieved. Therefore, at this time, the request is deemed not medically reasonable and 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the upper and 
lower abdomen. 
 
You asked the Plan to pre-approve CT scan services. You say that the requested imaging services are medically 
necessary. The Plan denied your request. The Plan says the criteria for CT scan services have not been 
satisfied. 
 
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 CT scan services. Our reviewer says 
that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the 
enrollee is a 76-year-old female who reports abdominal pain as well as confusion, cough, dizziness, fatigue, 
falls, lightheadedness, nausea, and shortness of breath. The abdominal symptoms were described as occasional 
sharp gas pains. She also has trouble with swallowing, has constipation, and chokes at times all of which is 
chronic. She was noted to have suprapubic tenderness. A request was made for CT scan of the upper and lower 
abdomen. However, this patient has not yet had an x-ray, colonoscopy, stool testing, or ultrasound or 
documentation of exhaustion of treating her constipation all of which should come before considering 
advanced imaging. There was no sign of a red flag diagnosis from the most recent examination to justify earlier 
consideration for advanced imaging. Therefore, this request for abdominal CT will be considered not medically 
necessary at this time based on the provided documentation.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) scan of the upper and lower abdomen.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines the long term acute care hospital services you are requesting do not meet the requirements 
for approval. 
 
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 there is no advantage in transferring the enrollee to the LTACH. The enrollee can 
remain at the current acute care hospital until such time no acute services are required. The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
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 enrollee would meet the criteria for a group 3 power wheelchair with no power 
options. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 medically reasonable or necessary. Our physician reviewer found that the enrollee is 
not a high risk for skin breakdown and does not use a catheter. She does not require special positioning because 
of spasticity. She does not require an expandable controller as her upper body strength is adequate for standard 
switches 
 
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 group 3 power wheelchair and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need intensive physical and occupational 
therapy. 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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your 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 acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ReActive8 device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the ReActiv8 device in the setting of 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is considered experimental/investigational. Therefore, the request is deemed not 
medically reasonable and 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ReActive8 device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says bilateral positive airway pressure (BiPAP) would be sufficient to meet the 
enrollee's needs. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the 
enrollee has severe chronic obstructive pulmonary disease (COPD). Arterial blood gas (ABG) studies during a 
recent hospitalization were consistent with acute on chronic hypercarbic respiratory failure. The enrollee may 
benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep. But Medicare does not cover a home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 24, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations, and the date of consultations in the patients medical record. 
There was no documentation of contact in the patient record. The listing of a referring provider on the claim 
does not satisfy the documentation criteria. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on May 24, 2022.