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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the appropriate level of care 
for the enrollee. You say that the enrollee is medically stable to be transferred to the LTACH at this time. The 
Plan denied your request. The Plan says the LTACH 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 LTACH care is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 
have not been met. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care setting. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the device is medically necessary 
and a covered device with Medicare. The Plan denied your request. The Plan says the MyoPro is considered 
investigational due to the lack of clinical evidence demonstrating an impact on improved health outcomes. The 
clinical value and effectiveness of MyoPro orthotic device in the setting of partial paralysis after CVA 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 a MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records provided and current clinical guidelines there is no 
documentation that the MyoPro orthotic device at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee. Current clinical guidelines designate robotic therapy to be of 
"uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven 
benefit in the home environment. Although records from the device manufacturer/vendor argue medical 
necessity of the requested device, records from the enrollees actual treating provider do not clarify why the 
requested device is the most appropriate treatment for the enrollees condition. In addition, provided records 
report the enrollee has right upper extremity spasticity which may be a contraindication to use of the device. 
The enrollees medical record must contain sufficient documentation of his medical condition to substantiate 
the necessity for the type and quantity of items ordered and for the frequency of use or replacement. The 
information should include the enrollees diagnosis and other pertinent information including, but not limited 
to, duration of the enrollees condition, clinical course (worsening or improvement), prognosis, nature and 
extent of functional limitations, other therapeutic interventions and results, past experience with related items, 
etc. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injections.

You asked the Plan to pre-approve epidural steroid injections. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered medically reasonable and necessary when specific criteria are met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve epidural steroid injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee clearly does not meet Medicare rules due to failure to obtain the 50% or greater threshold for pain that is required for a repeat injection. The review indicates that the enrollee does not meet the coverage criteria detailed in the LCD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that delaying care would prohibit the enrollee's ability to 
get back to maximum level of function. The Plan denied your request. The Plan says the request 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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD). 
 
You asked the Plan to pre-approve PCD. You say that you tried pneumatic cuffs and saw a visible difference in 
the swelling of your feet and legs. The Plan denied your request. The Plan says you do not meet criteria for this 
pneumatic compression device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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 PCD. Our reviewer says that you do not 
meet the Medicare criteria for a PCD. Our physician reviewer found you are noted to have lower extremity 
lymphedema. There is no documentation of truncal edema. There is no evidence that you have completed a 
course of standard therapy. There is no evidence that you used a basic pump device (such as E0651) for four 
weeks resulting in treatment failure or intolerance. Therefore, the documentation does not support that an 
advanced leg pump E0652 is currently medically reasonable or necessary for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PCD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (PCD).
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 are appealing the denial. 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), home with home health services or home with outpatient
therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues
to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement
however, the documentation doesn't support that they 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the enrollee 
does not require skilled nursing or therapy services on a daily inpatient basis. 
 
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 the enrollee has a past medical history of multiple comorbidities. She resides in a long-term facility, 
and was hospitalized for influenza A. She was discharged with physical, occupational, and speech language 
therapy services in the facility. The clinical documentation shows that the enrollee is still not at her functional 
baseline but is making progress with daily skilled therapy. The evaluating therapists recommend continued 
daily services. The enrollee has a change in medical status which requires skilled nursing. From a practical 
standpoint, continued daily services in a SNF are 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 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 skilled 
nursing facility (SNF) services.  
 
 
 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 pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee is clinically stable to transfer to an LTACH level of care. You say that this will provide the enrollee with the appropriate level of care to fully recover and get back to the independent lifestyle they had before. The Plan denied your request. The Plan says the requirements for admission to the LTACH have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be more stable and improving and should only require short-term additional acute care services that can safely be provided at the current facility. Transfer to the LTACH would not be clinically advantageous at this time and completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0274 and D0350) on July 25, 2022 
 
You asked the Plan to pay for the dental services (D0274 and D0350). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service (D0274) was exhausted on date of service January 14, 2022. While 
dental service (D0350) is being denied due to the service not being covered under the members plan. 
Therefore, we decided that the Plan does not have to pay for the dental services (D0274 and D0350) on July 25, 
2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs admission to a rehabilitation 
facility. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient rehabilitation 
facility services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found the clinical documentation shows that the enrollee does have functional 
impairments but there are no complex functional deficits specified thus intense therapy or interdisciplinary 
team management in an IRF would not be required. Document shows that the medical conditions are stable and 
would not require close medical supervision on an inpatient basis during rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and an intraoral/panoramic 
x-ray provided on July 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 29, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation and an 
intraoral/panoramic x-ray provided on July 14, 2022.
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 would like to request reconsideration of the denied authorization. The Plan denied your request. The Plan says the services requested 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 document does not support the medical necessity for admission to an IRF due to lack of medical complexity and lack of 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve treatment, mouth and face pictures, blocked nerve 
canal treatment, a crown, and core buildup services provided on June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the nerve 
treatment, mouth and face pictures, blocked nerve canal treatment, a crown, and core buildup services provided 
on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve) (64555). 
 
You asked the Plan to pre-approve percutaneous neuromodulation therapy. You say that the enrollee has tried 
all alternative methods of treatment and they have failed so you really need this approved. The Plan denied 
your request. The Plan says There are not enough studies to show this nerve procedure improves the health of 
patients with your problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Percutaneous Neuromodulation Therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve 
(excludes sacral nerve) (64555).