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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 records show that you had hip repair surgery and now need minimal assistance 
with transfers and ambulation. You need supervision for basic activities of daily living. You do not require intensive rehabilitation services for recovery from the uncomplicated hip repair surgery. The IRF services are 
not reasonable or 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need more therapy. The Plan denied your 
request. The Plan says daily skilled nursing or rehabilitation services are not required. 
 
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 physician reviewer 
found that a transfer from an inpatient rehab facility to a skilled nursing facility was requested. You remain at a 
moderate to minimal assist level for transfers. You have improved to a contact guard assist for ambulation. You 
have not completed your course of therapy, and you have not reached a functional plateau. You are responding 
to therapy at the current facility. Therefore, the request 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) 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 IRF care is medically necessary, and the enrollee 
meets the rehabilitation criteria. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 is deconditioned and has dementia. The enrollee can walk 60 feet with a walker, and his dementia impairs his ability to participate and benefit from intensive therapy even if it was 
indicated. The enrollee does not require intensive rehabilitation or 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve a continuation of SNF care. You say that you cannot walk on your own and 
are not ready to return home. The Plan denied your request. The Plan says that the request 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 a continuation of SNF care. Our 
reviewer says that the requested SNF care is considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found that medication changes have been made, complex wound care is still 
required. The continued assessment and treatment by skilled nursing is required. Clinical documentation shows 
that you are improving but functional impairments and skilled therapy is still medically necessary. From a 
practical standpoint you still require continued daily skilled services on an inpatient basis in a SNF. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve a continuation 
of SNF care.  
 
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 home ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. You say that it is felt that this is a necessary 
treatment. The Plan denied your request. The Plan says the requested device exceeds the enrollee's need. 
 
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 requested ventilator. Our reviewer 
says that the requested ventilator is not considered medically reasonable and necessary. Our physician reviewer 
found the 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 bilevel positive 
airway pressure (BiPAP) device with AVAPS and a back-up rate.   
 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 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services. 
 
You asked the Plan to pre-approve the requested HHA services. You say that you need assistance with daily 
living activities which your spouse is not able to provide any longer. You feel this is medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. The request is for assistance with 
custodial care which is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file and Medicare rules. At this time, there is no request for skilled nursing or skill therapy 
services. Home health aide services are only covered when skilled care is being provided. Based on this 
information, we decided that Medicare rules for coverage of the requested HHA services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve home health aide (HHA) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
zoledronic acid. 
 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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, zoledronic acid. The reviewer found that there is no 
documentation provided indicating that the plans required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
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 need IRF care. The Plan denied your request. 
The Plan says IRF care 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 that you are medically stable and does not need a physical medicine and 
rehabilitations physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. At your current functional mobility, you do 
not need 3 hours a day for 5 days a week of therapies with multidisciplinary approach in an IRF. You have no 
rehabilitation nursing needs other than routine nursing care and have no medical complexity. While you may 
benefit from physical therapy and occupational therapy, your rehabilitation needs can be safely met in an 
alternate and low intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epideral steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve the ESI. 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 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 SAME scale* for at least three months.7,8 If a patient 
fails to respond well to the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, 
level and/or medication if appropriate, with the rationale and medical necessity for the second ESI documented 
in the medical record. 
 
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 ESI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation does not reveal that the 
patient has had at least 50% of sustained improvement in pain relief and/or improvement in function measured 
from baseline using SAME scale for at least three months from prior injection.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the epideral steroid injection (ESI) (62323).
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 enrollee is very active and would benefit from 
therapy three hours a day. You say the doctors feel the enrollee is a perfect candidate for acute rehabilitation. 
The Plan denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs 
can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation 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 does not support that the enrollee would meet criteria for 
admission to an acute inpatient rehabilitation 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 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. The Plan denied your request. The Plan says you do not need 
three hours of therapy per day. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for renal failure, sepsis, respiratory failure, and endocarditis. Your 
medical problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says there is not enough evidence to show 
that the requested device would improve the outcome for your condition. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that at issue is the medical appropriateness and necessity of implantation of the 
wireless pulmonary artery pressure monitoring system CardioMEMS for management of congestive heart 
failure (CHF) in this patient. The CardioMEMS device was approved by the Food and Drug Administration 
(FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of 
pulmonary artery pressure in the management of patients with CHF. The clinical study on which FDA approval 
was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary 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 CardioMEMS device. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the enrollee has a history of 
atrial fibrillation and was experiencing complications when attempting to change medication. The Plan denied 
your request. The Plan says an implantable loop recorder 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 an implantable loop recorder. Our 
reviewer says that implantable loop recorder is not considered medically reasonable and necessary in this case. 
Our physician reviewer found while the enrollee has a history of palpitations and atrial fibrillation, there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an implantable loop recorder. There is insufficient documentation to support the medical 
necessity for insertion of an implantable loop recorder in the enrollee's 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 an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravitreal injection of a pharmacologic agent (separate 
procedure) provided to the enrollee on June 15, 2022. 
 
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no additional documentation or confirmations that indicate or support an additional study 
which was billed; therefore, one unit remains denied. 
 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 67028 is "Intravitreal injection of a pharmacologic agent 
(separate procedure)." 
 
We asked our coder 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 injection. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report includes 
insufficient documentation to confirm units of service, as LT, RT, Bilateral is not documented in the medical 
record. Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for intravitreal injection of a pharmacologic agent (separate procedure) provided to the enrollee on 
June 15, 2022.