Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat trigger point injections. 
 
You asked the Plan to pre-approve repeat trigger point injections. You say that repeat trigger point injections 
are medically necessary. The Plan denied your request. The Plan says repeat trigger point injections are 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 repeat trigger point injections. Our 
reviewer says that the requested repeat trigger point injections are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that trigger point injections are considered medically 
necessary when provided as part of a comprehensive pain management program, which includes physical 
therapy, patient education, psychosocial support, and oral medications, where appropriate.  The clinical 
information provided does not describe these criteria, and therefore, the requested repeat trigger point 
injections are not indicated at this time. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat trigger point injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve repeat trigger point injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs can safely be 
met/monitored at an LTACH. The Plan denied your request. The Plan says an LTACH is not medically 
necessary. 
 
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 that the enrollee is receiving appropriate care at the present acute care setting. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says the requested scan 
is not indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that a positron emission tomography (PET) scan is 
only covered under certain medical indications. 
 
We looked at the file and Medicare rules. A PET scan for initial treatment of prostate cancer is not covered. 
Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the enrollee is stressed and has 
heart problems. The Plan denied your request. The Plan says that this request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 inpatient hospital admission. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the admitting physician reasonably expects that the patient's necessary hospital care 
will span two midnights. 
 
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 inpatient hospital admission have been met. Therefore, we decided that the 
Plan has to pre-approve an inpatient hospital admission.  
 
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 continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that you keep better control of your sugar 
with the device. The Plan denied your request. The Plan says you do not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that you perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, or require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic 
connection, and footplate. 
 
You asked the Plan to pre-approve an expandable controller, harness, electronic connection, and footplate. You 
say that the services are not medically 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 wheelchair accessories are covered 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 an expandable controller, harness, 
electronic connection, and footplate. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found in this case, you have a neurologic disorder with functional deficits. You meet 
criteria for use of a power mobility device. The requested accessories are not medically necessary as you do 
have use of your hands and can operate and control the power options using the switches that are included in 
the basic wheelchair. Furthermore, the documentation does not indicate that you require a specialized foot 
plate. 
 
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 expandable controller, harness, electronic connection, and footplate have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, 
electronic connection, and footplate.
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's functional status is below her baseline. 
The Plan denied your request. The Plan says the enrollee is unable to participate in three hours of therapy a 
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 the enrollee suffered a shoulder dislocation, pelvic fracture, and large pelvic hematoma in a fall. She is in 
too much pain to bear weight. She transfers with maximal assist.  The complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that she will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
The documentation does not support that she requires at least 3 hours a day. 
 
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 Ipilimumab (J9228) and Nivolumab (J9299). 
 
You asked the Plan to pre-approve Ipilimumab and Nivolumab. The Plan denied your request. The Plan says 
the use of this drug/regimen is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Ipilimumab and Nivolumab. Our 
reviewer says that Ipilimumab and Nivolumab are not medically reasonable and necessary for the enrollee. Our 
physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated 
for the enrollee's condition. Our reviewer found that the Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. Our physician reviewer also found that 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 Ipilimumab and Nivolumab have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Ipilimumab (J9228) and Nivolumab (J9299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for hand/wrist surgery. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are available in-state. 
 
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 
an out-of-network referral for hand/wrist surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. While the 
enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing facility or in-home with services. 
 
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 MyoPro power-assisted arm brace. 
 
You asked the Plan to pre-approve the MyoPro brace. You say that it is felt that this device will help improve 
the enrollee's level of function. The Plan denied your request. The Plan says this is not a medically necessary 
device based on current 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 MyoPro brace. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found notes from the doctor on February 2, 2022, indicate that the enrollee came to the 
appointment to discuss "MyoPro" and that the enrollee was "dropping items frequently." However, the 
preprinted supplied prescription indicates that the provider signed the form January 26, 2022. There is no 
evidence that the physician or nurse practitioner has evaluated the enrollee regarding the ability to use this 
device safely. This MyoPro form includes an assessment of spasticity by the MyoMo employee, but this 
paperwork is documented as being performed by "candidate photos" and not performed in person.  The documentation also does not include any clear evidence or records of a recent trial of physical therapy for 
the arm. The review has determined that the items/services at issue in this case are 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 the MyoPro brace have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro power-assisted arm brace.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick external female catheter. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are partially paralyzed from a 
history of falls. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a PureWick external female 
catheter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric hospital services beyond April 18, 2022. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. The Plan denied your request. The 
Plan says that this request is not medically necessary because the records received show that your condition has 
improved, and you are no longer a threat to yourself or others. 
 
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 pre-approve inpatient psychiatric hospital services. 
Our reviewer says that the health plans denial of continued inpatient psychiatric services is inappropriate. Our 
physician reviewer found it was expected that you would improve in a reasonable period of time for the dates 
in question as although you did not have suicidal or homicidal ideation, auditory or visual hallucinations, you 
were pacing, agitated and depressed. It does appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care. Active treatment was taking 
place and the services are reasonably expected to improve your condition or for the purpose of diagnosis. The 
record does not include an individualized treatment plan. The records were supervised and evaluated by a 
physician. Based upon review the records provided for the admission of this patient does meet the criteria for 
April 18, 2022 forward. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric hospital services beyond April 18, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional direct skilled nursing services of a registered 
nurse (RN) (G0299). 
 
You asked the Plan to pre-approve direct skilled nursing services of a RN. You say that you have acute 
Alzheimers and cannot remember to take your medication on your own. You also say that you need home care 
because you are unable to care for yourself. The Plan denied your request. The Plan says the records do not 
support the need for a skilled nurse to make more visits. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 direct skilled nursing services of a RN. 
Our reviewer says that the requested home health skilled nursing services are not medically necessary or 
reasonable. Our physician reviewer found you do not have documented skilled nursing 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 direct skilled nursing services of a RN have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional direct skilled nursing services of a registered 
nurse (RN) (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee can undergo stress testing to assess the presence and severity of ischemia. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has a positive family history of coronary artery disease, with a negative stress 
test in 2017, a recent inconclusive cardiac CT scan, and a normal echocardiogram. Documentation does not 
support the rationale for the requested 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization services.