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 you disagree with the denial. The Plan denied your 
request. The Plan says the services 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on February 15, 2023 with altered mental status, shortness of breath, and worsening renal failure. A 
right thoracentesis was performed on February 16, 2022. The physical therapy note dated February 23, 2023 
states he needs minimal assist for sitting up, bed/chair transfers, and walking 60 feet with a rolling walker. He does not require the intensity of services provided at an IRF. Specifically, he is not shown to require 15 hours 
per week of rehabilitative services and regular physician evaluation. 
 
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 oxygen concentrator, single delivery port, capable of 
delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E01390). 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that the stationary and portable oxygen is 
medically necessary for the enrollee due to simple chronic bronchitis. The Plan denied your request. The Plan 
says the criteria for E1390 oxygen concentrator has not been met and is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
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 oxygen concentrator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has chronic obstructive pulmonary disease and dyspnea. On an oximetry 
testing during an office visit on November 29, 2022, the oxygen saturation breathing room air during exercise 
fell to 87% and corrected to 94% during exercise breathing oxygen at 2 liters per minute. This qualifies the 
enrollee for supplemental oxygen during exercise, and that has been approved as the Plan approved portable 
gaseous oxygen system, rental; E0431. There is no documentation of an oxygen saturation less than 89% 
breathing room air at rest, or during sleep. A stationary home oxygen concentrator is considered not medically 
necessary, because Medicare criteria have not been 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 an oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a oxygen concentrator, single delivery port, capable of delivering 85 percent or 
greater oxygen concentration at the prescribed flow rate (E01390).
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 is in need of inpatient rehabilitation 
facility admission. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level 
of care such as 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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that further structured rehabilitation would help you get 
back to your independence as quickly as possible. The Plan denied your request. The Plan says a SNF 
admission is not medically necessary, and your needs can be met at an alternate level of care. 
 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 that 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 or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
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 Stelara.  
 
Benefits for Stelara 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: 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 prefer to go to a rehab rather than a nursing 
home to improve. The Plan denied your request. The Plan says your therapy needs can be safely fulfilled at 
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 you have complex medical issues. Your documented nursing, medical and 
rehabilitation needs would not be expected to 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are bed bound with Covid and need SNF 
services. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do 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 require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a 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 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 SNF care.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the left knee. 
 
You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says that a CT scan to 
support computer-assisted surgical navigation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our physician reviewer 
found that the enrollee has a history of knee pain and arthritis. The enrollee is planning to have left total knee 
arthroplasty. The surgeon is planning to use robotic technique ("MAKO"). A preoperative CT scan was ordered 
in preparation for the MAKO knee arthroplasty. Mako uses a 3D CT-based planning software so that a surgeon 
can diagnose a person's unique anatomy and then create a custom joint, knee, or hip replacement surgical plan. 
The review indicates that the requested CT Scan is 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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the left knee.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Xgeva (J0897). 
 
You asked the Plan to pre-approve Xgeva. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Xgeva. Our reviewer says that the 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of cholangiocarcinoma with bony metastasis. The FDA has stated that the requested 
drug is indicated for the enrollee's condition. The rules state that the requested drug is covered when the 
enrollee is taking calcium and vitamin D supplements as necessary to treat or prevent hypocalcemia. The 
record indicates that the enrollee has a calcium level of 9.8 mg/dl. Supplementation is not necessary at this 
time. The elements of the coverage criteria are 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 Xgeva have been met. Therefore, we decided that the Plan has to pre-approve 
treatment with Xgeva (J0897).  
 
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 arterial catheter placement and revascularizations. 
 
You asked the Plan to pre-approve vascular procedures. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says that the records do not show non-invasive testing or a 
plan to perform an intervention. 
 
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 vascular procedures. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has diabetes, renal failure, and numerous risk factors for arterial occlusive disease. 
The enrollee has a non-healing wound at the site of the third toe amputation with evidence of gangrene 
including involving adjacent tones. The enrollee is at high risk for limb loss. While noninvasive studies are 
often obtained at this point in a similar patient's care, the results are generally unreliable in diabetic/renal 
failure patients and it would not be recommended delaying angiography and potential intervention to review 
this. Although the documentation does not explicitly state that angiography is planned, the documentation of 
distal gangrene is overwhelmingly supporting of this plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vascular procedures have been met. Therefore, we decided that the Plan has to 
pre-approve arterial catheter placement and revascularizations.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq 25MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Myrbetriq is a self-administered drug and does not fall under Part B coverage. 
 
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 Myrbetriq 25MG tablet.  
 Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular study (93924) provided on August 15, 2022. 
 
You asked the Plan to pay for the vascular study. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that non-invasive vascular studies are covered for the 
indications established in the applicable LCD. 
 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 pay for the vascular study. Our reviewer says that 
the requested services are not medically reasonable and necessary in this case. Our physician reviewer found 
that the only documentation provided with respect to indications, is that the procedure is being performed for 
leg pain. The documentation provided does not describe the nature of the leg pain, pulse status of the enrollee, 
and the rationale for the more complex expensive test. 
 
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 vascular study have not been met. Therefore, we decided that the Plan does 
not have to pay for the vascular study (93924) provided on August 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee attempted therapy 
but was discharged due to lack of improvement and continued pain. The Plan denied your request. The Plan 
says there is no documentation to support an expectation that the enrollee will require greater than 2 midnight 
stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this 
case. Our physician reviewer found this procedure is currently approved as an ambulatory procedure. There is 
no documentation provided to support the expectation that the enrollee will require a greater than 2 midnight 
stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital level of care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve suprapubic fat pad excision. 
 
You asked the Plan to pre-approve suprapubic fat pad excision. You say that the requested suprapubic fat pad 
excision is medically necessary. The Plan denied your request. The Plan says the requested suprapubic fat pad 
excision 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 suprapubic fat pad excision. Our 
reviewer says that the requested suprapubic fat pad excision is not medically necessary. Our physician reviewer 
found the record indicates that the enrollee has a body mass index of 37 that causes a significant suprapubic fat 
pad. The provided record does not document that the requested procedure is being performed to repair a 
malfunctioning body member or to repair a congenital defect. The primary source record provided does not 
establish the non-cosmetic nature of the requested procedure. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules of the requested service. The elements of 
the coverage criteria are not satisfied. The requested service is not 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 suprapubic fat pad excision have not been met. Therefore, we decided that the 
Plan does not have to pre-approve suprapubic fat pad excision.