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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for the enrollee to receive 
the therapy needed and regain their strength, mobility and independence before returning home. The Plan 
denied your request. The Plan says the services the enrollee needs can be provided safely in another setting 
such as 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 enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the health plan has no contractual obligation to cover services that are not covered by 
Medicare. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that 90% pain relief was achieved for only six weeks from the injection on 12/9/22. The LCD criteria for 
repeat ESI is 50% or greater pain relief for three months. This was not documented and therefore, the request is 
deemed 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary Our physician reviewer found that in 
this case, the enrollee's provider is requesting multiple injections in more than one spinal region to be injected 
at the same session. The review has determined that the requested ESI does not meet the Medicare LCD 
coverage criteria. 
 
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 epidural steroid injection. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D2950 x 13, D2740 x 10, D6740 x 4, 
D330 x 1, D3950 x 1, D6245 x 3, D6010 x 3, D6056 x 3, and D6058 x 3) 
 
You asked the Plan to pre-approve the dental services. You say that these service are medically necessary. The 
Plan denied your request. The Plan says your benefit for the requested items or services 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. Therefore, we decided that the Plan does 
not have to pre-approve dental services (D2950 x 13, D2740 x 10, D6740 x 4, D330 x 1, D3950 x 1, D6245 x 
3, D6010 x 3, D6056 x 3, and D6058 x 3)
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 right side of your body has temporary paralysis 
on right side of body, and you need therapy in order to do daily activities. The Plan denied your request. The 
Plan says you do not meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility (IRF). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve External mobile cardiovascular telemetry with 
electrocardiographic recording (93228). 
 You asked the Plan to pre-approve the outpatient surgery. You say that the external mobile cardiovascular 
telemetry was re-ordered by your covering locum. 
 The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 outpatient surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has palpitations at rest and when walking 10 steps or more which occur 
twice daily on average. No previous monitoring studies had been performed. A request was made for an 
external mobile cardiovascular telemetry. However, the provided documentation did not clearly describe why 
the standard of care for initial testing for daily palpitations, 24-hour ambulatory ECG, Holter monitor, was not 
recommended or performed or that it was contraindicated for any reason. The Holter would quickly and less 
expensively acquire the important information about any arrythmia present as the palpitations occur daily 
according to the documentation. Therefore, the Medicare criteria for 93228 is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve External mobile cardiovascular telemetry with electrocardiographic recording 
(93228).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says the requested IRF services 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 the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for the enrollee to receive 
physiatry follow up and receive daily therapy. The Plan denied your request. The Plan says the enrollee's 
therapy needs are greater than what acute inpatient rehab can provide. 
 
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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve onabotulinumtoxina (Botox) (J0585). 
 
You asked the Plan to pre-approve Botox. You say that you need this to be approved. The Plan denied your 
request. The Plan says drugs that are pharmacy shipped to a provider are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve onabotulinumtoxina (Botox) (J0585).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a seat lift mechanism. We decided that the Plan does not have to 
pre-approve a seat lift chair.  
 
You asked the Plan to pre-approve a seat lift chair and mechanism.. You say that a recliner lift chair is 
necessary. The Plan says that the seat lift mechanism is not medically necessary. 
 
We decided that the Plan has to pre-approve a seat lift mechanism.  
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed 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 the seat lift mechanism. Our reviewer says that you 
require a power seat lift chair per guideline criteria. You have severe hip osteoarthritis that will ultimately 
require hip arthroplasty. You are documented to require assistance for performing transfers from a regular 
armchair and are unable to accomplish this without a risk for falling. You can ambulate in your home with the 
assistance of a rollator. Therefore, the requested power seat lift chair is medically necessary, and we decided 
that the Plan has to pre-approve a seat lift mechanism.  
 
We also decided that the Plan does not have to pre-approve a seat lift chair. 
 
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism.  
 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve 
a seat lift chair. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the percutaneous revascularization (minimally invasive procedures 
used to open clogged coronary arteries (those that deliver blood to the heart) of your leg (37229, 37228, 37227, 
37226, 37225, 37224, 37223, 37222, 37221, 37220, 75710). 
 
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 documentation supports the medical necessity of the procedure in question. You have 
documentation of lifestyle limiting, short distance claudication, and computed tomography angiography (CTA) 
confirmation of left external iliac artery occlusion. Claudication from iliac occlusive disease tends to be quite 
disabling and unlikely to substantially improve with conservative measures. As a next step, angiography and 
possible intervention is both reasonable and 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve the percutaneous revascularization (minimally invasive procedures used to open clogged coronary 
arteries (those that deliver blood to the heart) of your leg (37229, 37228, 37227, 37226, 37225, 37224, 37223, 
37222, 37221, 37220, 75710).  
 
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 proton beam radiation treatment delivery (code 77523). 
 
You asked the Plan to pre-approve proton beam radiation treatment delivery. You say that proton beam 
radiation treatment delivery is medically necessary. The Plan denied your request. The Plan says proton beam 
radiation treatment delivery 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 proton beam radiation treatment 
delivery. Our reviewer says that the requested proton beam radiation treatment delivery is not considered 
medically reasonable and necessary in this case. Our physician reviewer found Proton therapy is not in and of 
itself investigational, but rather a Food and Drug Administration (FDA) approved tool available to clinicians to 
treat patients with radiotherapy. For esophageal cancer, treated to 45-40.4 Gy, proton therapy is not likely to be 
medically necessary. There is a paucity of data to support its use. The potential benefit of proton therapy is 
being investigated in an ongoing cooperative group study (NRG GI006 ttps://www.nrgoncology.org/Clinical-
Trials/Protocol/nrg-gi006?filter=nrg-gi006). 
 The enrollee reportedly agreed to consent to a registry study which seems to enroll any patient receiving proton 
therapy for any disease (which in my opinion should not be sufficient for claiming medical necessity, as any 
and all patients treated with radiation therapy could then be considered for proton therapy without 
consideration for true need of this service). Notably, registry studies are not clinical trials or studies, and have a 
much less rigorous development process.  A tumor registry does not address a specific scientific question but 
rather registers the patients clinical and treatment information into a database for potential analysis in the 
future. Nevertheless, it is not specified if a clinical trial review was sought or whether this insurer allows for 
clinical trial exceptions. In summary, for this case, the need for proton therapy is not supported with a plausible 
dosimetric rationale but rather being offered as routine care. Thus, proton therapy would not be furnished in 
accordance with accepted standards 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 proton beam radiation treatment delivery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve proton beam radiation treatment delivery (code 77523).
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 a SNF admission is medically necessary. The Plan 
denied your request. The Plan says the member is best suited for long-term care for therapy. 
 
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 the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to ADLs 
with minimal supervision. Daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. The enrollees care needs can be provided at a lower 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that Synvisc is medically necessary. The Plan denied your 
request. The Plan says a trial of Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One is required before 
alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Synvisc. Our reviewer says that 
Synvisc is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.