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 you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the coverage 
criteria has 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 appears to be currently unstable and requires additional acute care 
hospital services that can safely be administered at the current facility until more stable and appropriate for 
transfer. The enrollee does not require services at the LTACH that are not already available at the current 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve a supply allowance. You say that due to the enrollee's diagnoses, it is 
significantly challenging if not impossible for them to perform finger sticks. You also say that this CGM would 
improve the enrollee's overall health. The Plan denied your request. The Plan says this request does not meet 
the requirements for approval. 
 
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 indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
supply allowance have not been met. Therefore, we decided that the Plan does not have to pre-approve a supply 
allowance for a continuous glucose monitor (CGM).
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 needs inpatient rehab admission in order 
to regain her prior level of function, the medical management and rehabilitation needs require an inpatient 
rehabilitation stay and close physician supervision to return home at the maximum level of functioning with 
decreased risk for readmission. The Plan denied your request. The Plan says the records do not show that the 
enrollee needs and is able to take part in 3 hours of therapy a day at least 5 days a week or 15 hours per week, 
services needed can be provided safely in other settings, a skilled nursing facility, 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 complexity of the enrollee's 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the enrollee requires 
air mattress to help prevent bed sores and maintain function. The Plan denied your request. The Plan says under 
Medicare guidelines, your request is not medically necessary because your records show you do not have any 
pressure ulcers or recent surgery for a pressure ulcer.  
The Plan follows Medicare rules. Medicare rules say that the enrollee must meet the criteria listed in the rules 
section of this letter for coverage of the requested item. 
 
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 powered pressure-reducing air 
mattress. Our reviewer says that the item is not medically necessary. Our physician reviewer found that the 
provided records in this case do not document that the enrollee has multiple stage 2 pressure ulcers located on 
the trunk or pelvis or that the enrollee has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis, 
or that the enrollee has had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within 
the past 60 days as required by 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 a powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
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 physical and occupational therapy to gain 
his strength and so you can move yourself, your physicians are setting up home health care, but you need more 
than this. The Plan denied your request. The Plan says you do not require intensive therapy services or 3 hours 
of therapy a day, medically necessary care may be provided safely in a lower level of care. 
 
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 enrollee's nursing, medical and rehabilitation needs do 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services 
requested 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 acute IRF admission and services.
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 recently you had your right leg amputated and need 
aggressive rehabilitation to learn how to care for yourself with the new circumstances and regain your mobility. 
You also have developed a heart problem (Afib)and need to be monitored with the new medication you have 
started to take. The Plan denied your request. The Plan says the request is not medically necessary, the services 
you need can be provided safely in other settings, for example, a skilled nursing facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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 acute IRF admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Procrit (J0885). 
 
You asked the Plan to pre-approve Procrit. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that erythropoiesis stimulating agents (ESAs) may be 
covered when certain 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 Procrit. Our reviewer says that the 
requested drug, Procrit, meets the criteria for coverage. Our physician reviewer found the record indicates that 
the enrollee has anemia in stage III chronic kidney disease. The record indicates that the hemoglobin is less 
than 10 mg/dl and a glomerular filtration rate of 29. Therefore, the reviewer found that the requested drug 
meets the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have been met. Therefore, we decided that the Plan has to pre-approve 
Procrit (J0885).  
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need physical therapy to help you with your 
balance and mobility. You say you need assistance with walking to keep you from falling. The Plan denied 
your request. The Plan says the IRF services requested 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 that you are deconditioned post-acute illness. You are functioning at minimal 
assistance and able to walk 100 feet. You do not require intensive rehabilitation services by evidence based and 
clinical practice standards. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulation (PNS). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the current peer-reviewed data does not support this request. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that currently, implantable peripheral nerve stimulators for chronic pain are still being studied to see if 
this treatment is reasonable and necessary. Overall, there is lack of evidence to support PNS over traditional 
treatment of chronic back pain and the lack of literature evaluating long-term efficacy and adverse events 
associated with implantable PNS devices. Long-term data are especially important for these technologies due to 
the invasive (and in some cases, permanent) nature of these devices. There were no published studies 
evaluating the SPRINT PNS System identified. Overall, there is lack of evidence to support PNS over 
traditional treatment of chronic back pain. There is also a lack of literature evaluating long-term efficacy and 
adverse events associated with implantable PNS devices.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve peripheral nerve stimulation (PNS).
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 the enrollee's records 
do not show the need and are able to take part in 3 hours of therapy a day at least 5 days a week or 15 hours per 
week, services needed can be provided safely in other settings, a skilled nursing facility, 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 complexity of the enrollee's 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blood glucose test strips. 
 
You asked the Plan to pre-approve blood glucose test strips. You say that you already have equipment for this 
brand of test strips. The Plan denied your request. The Plan says only the preferred brand products listed in the 
EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits.  
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve blood glucose 
test strips.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the cervical fusion surgery (22600, 22614 and 22842). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show there is severe stenosis and myelopathy with spinal cord compression. The 
enrollee has failed conservative measures. Surgery needs to be done. The services should be approved for 
decompression and fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve the cervical fusion surgery (22600, 22614 and 22842).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant (33340). 
 
You asked the Plan to pre-approve the percutaneous transcatheter closure of the left atrial appendage with 
endocardial implant. 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 Percutaneous Left Atrial Appendage Closure is 
considered medically necessary when the criteria listed in the Medicare Rules section is 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 percutaneous transcatheter closure 
of the left atrial appendage with endocardial implant. Our reviewer says that the service is not medically 
necessary. Our physician reviewer found there is no apparent contraindication to anticoagulation. As such, 
guidelines would not support implantation of a LAAC in this 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 percutaneous transcatheter closure of the left atrial appendage with 
endocardial implant have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
percutaneous transcatheter closure of the left atrial appendage with endocardial implant (33340).