Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 8 physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee will continue to benefit from 
skilled physical therapy to improve hip strength, balance, and endurance. You say that the enrollee can 
decrease their risk for falling and promote mobility in their home and community. The Plan denied your 
request. The Plan says an additional 8 physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee does not require the unique skills of a professional 
therapist to provide treatment safely and effectively. The services can be safely and effectively performed only 
by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design, or deliver a program to maintain the enrollee's current condition or to prevent or slow further 
deterioration. The enrollee can transition to a home exercise program with the already approved therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an additional 8 physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa (J8499). 
 
You asked the Plan to pre-approve Gemtesa. You say that you believe this drug should be approved for the 
enrollee due to their advanced age. The Plan denied your request. The Plan says this drug is not covered for the 
enrollee's condition by their Medicare Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa (J8499).  
 
Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain (70551). 
 
You asked the Plan to pre-approve an MRI of the brain. You say that the service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the requested MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the brain. Our physician 
reviewer found the enrollee is noted to have memory problems. It is a standard of care/practice to perform a 
structural neuroimaging study in the evaluation of dementia/memory impairments to rule in/out structural 
causes for such impairments. Our reviewer also found that in this setting, it can be said that the requested 
diagnostic testing would otherwise be consistent with standards of care and therefore would be 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 MRI of the brain have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the brain (70551).  
 
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 ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 the ventilator. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, the record indicates that the enrollee has chronic hypercarbic respiratory 
failure in the setting of chronic obstructive pulmonary disease, pulmonary hypertension, and diastolic heart 
failure. The record indicates that the enrollee has been treated with BiPAP.  The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated 
coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for your condition. 
The Plan denied your request. The Plan says the rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. 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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography (CPT code 93306). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 the service. Our physician reviewer 
found in the absence of any symptoms according to the submitted records. Clinical guidelines do not support 
carrying out a TTE in this setting. In summary, there is no supportive evidence for the medical necessity of a 
TTE 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve echocardiography, transthoracic, real-time with image documentation (2D), includes M-
mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow 
Doppler echocardiography (CPT code 93306).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Onivyde. 
 
You asked the Plan to pre-approve Onivyde. 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 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 Onivyde. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia, do not contain a supportive citation, as defined by Medicare rules, for the use of the requested drug 
in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for 
review. 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 Onivyde have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Onivyde.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen equipment (E0431, E1390). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that the equipment is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. Medicare rules also state that there is no further payment for oxygen equipment 
during the 5 year reasonable useful life of the equipment after the initial 36 months of rental payments are 
made. 
 
 
 
 
 
 
 The file shows that you have oxygen equipment already. The requested equipment serves the same purpose as 
the existing equipment. The existing oxygen equipment is less than 5 years old. More than 36 months of rental 
payment has been made. Coverage criteria is not met for new equipment. Therefore, we decided that the Plan 
does not have to pre-approve oxygen equipment (E0431, E1390).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroplasty, acetabular and proximal femoral prosthetic 
replacement (total hip arthroplasty), with or without autograft or allograft (CPT code 27130). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 the service. Our physician reviewer 
found there is no documentation that the enrollee failed three (3) months of conservative measures to include 
physical therapy (PT). 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip 
arthroplasty), with or without autograft or allograft (CPT code 27130).
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 prefer to be admitted to acute 
rehabilitation because you were independent and active before coming to the hospital. You say you are eager 
and motivated to complete the required three hours of therapy. 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 you are modestly deconditioned post-bypass surgery. You do 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: 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 this is not medically necessary. 
 
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 was apparently hospitalized in May 2022. A single progress note is provided, indicating diagnoses of 
heart failure with preserved ejection fraction (HFpEF), pulmonary hypertension, aspiration pneumonia, and 
obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP). The notes elsewhere indicate 
the patient has been using a Trilogy ventilator at home since a hospitalization in 2020. COPD is listed as a diagnosis on the order, but there is no data to support that. COPD is not listed as a diagnosis in the progress 
note, the patient is a lifetime nonsmoker, and there are no pulmonary function tests. OSA is listed but 
apparently the patient has never had a sleep study.  There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. There is no arterial blood gas (ABG) study done while stable showing chronic C02 
retention. If the patient does have OSA, may benefit from CPAP.  If the patient does have chronic CO2 
retention, may benefit from sleep study and pulmonary function tests to assess etiology. Medicare does not 
cover a home ventilator when used as bilateral positive airway pressure (BiPAP), or in the treatment of OSA.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this procedure is medically reasonable and 
necessary. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 
 
 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 HFCWOD. Our reviewer says that the 
requested device is not medically reasonable and necessary. Our physician reviewer found that the enrollee has 
chronic bronchitis and exertional dyspnea, presumably related to COPD. There is no diagnosis of cystic 
fibrosis, bronchiectasis, or neuromuscular disease. Medicare does not cover the HFCWOD for COPD or 
chronic bronchitis because there is inadequate evidence of efficacy for these diagnoses. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the SI joint, 
with image guidance (ie, fluoroscopy or computed tomography) (64625). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this treatment has not been proven as effective as standard treatment of SI 
joint pain. 
 
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 service. Our physician reviewer 
found radiofrequency ablation of the Si joint is experimental for back pain. More research is needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation, nerves innervating the SI joint, with image guidance (ie, 
fluoroscopy or computed tomography) (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT peripheral neurostimulator (PNS) system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says until results of clinical research definitively support the use of the SPRINT PNS system 
for chronic shoulder pain, it is not reasonable or necessary for Medicare coverage. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is insufficient data to support the use of a Sprint PNS for the pain arising from left shoulder 
osteoarthritis. The request is 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the SPRINT peripheral neurostimulator (PNS) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Iodoflex dressings (A6222). 
 
You asked the Plan to pre-approve the Iodoflex dressings. You say that these dressings are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Iodine dressings  other than iodoform gauze 
packing- are not considered medically necessary. 
 We looked at the file and Medicare rules. The type of dressing requested is not covered under Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of the Iodoflex dressings have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Iodoflex dressings (A6222).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says there is little evidence in the medical literature to 
suggest that this is an appropriate procedure for your back pain. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.