Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular revascularization. 
 
You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the most recent notes document that the 
enrollee denies claudication and leg pain. No pulse examination is documented. The ankle-brachial indices 
(ABIs) are normal. Earlier records document pain at rest. Pain at rest in the presence of normal ABIs is 
generally not consistent with a vascular etiology for the pain. The description of the enrollee's symptoms is 
limited. The services are not reasonable or medically necessary based on the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovascular revascularization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Olanzapine tablets. 
 
You asked the Plan to pre-approve Olanzapine tablets. You say that the enrollee is currently taking Olanzapine 
with moderate improvement. You also say that you believe a higher dose of Olanzapine is needed. The Plan 
denied your request. The Plan says Olanzapine tablet 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 Olanzapine tablets.  
 
Benefits for Olanzapine tablets 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that there has not been any improvement in your health 
and rehabilitation in the current facility you are in. You say you would benefit from being transferred to a 
different facility where your health and rehabilitation would get better faster. The Plan denied your request. 
The Plan says criteria for admission to the IRF have not been met. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 you are requesting inpatient rehabilitation so the 
enrollee can return safely to their prior level of function. The Plan denied your request. The Plan says that the 
enrollee's needs can be met at 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan. 
 
You asked the Plan to pre-approve a computerized tomography (CT) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the services 
requested are not medically necessary. 
 
The Plan must follow Medicare rules. 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 a computerized tomography (CT) scan. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found CMS does not 
allow this test for screening in an asymptomatic patient per NCD and LCD guidelines. 
 
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 computerized tomography (CT) scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computerized tomography (CT) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the requested facet joint injections. You say that this treatment should be 
approved for the enrollee's pain. The Plan denied your request. The Plan says LCD criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be covered when there is an 
absence of other probable cause of pain symptoms. 
 
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 requested facet joint injections. Our 
reviewer says that the facet joint injections at issue are not shown to be medically reasonable and necessary. 
Our physician reviewer found the imaging report shows a chronic L5 pars defect with grade 2 anterolisthesis of L5 on S1 resulting in severe right and moderate to severe left foraminal stenosis. There are other probable pain 
generators present and therefore, the request does not meet the LCD 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 the requested facet joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856) and related accessories. 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and related accessories. You say that 
the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for coverage for durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment. 
 
We looked at the file and Medicare rules. In this case, you are requesting a replacement for a power wheelchair 
received by the enrollee on October 19, 2020. Therefore, the requested replacement is for an item that has not 
outlasted its reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage 
of a Group 3 standard power wheelchair and related accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power option (K0856) 
and related accessories.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is your hope to return to your previous functioning 
level by participating in inpatient rehab and decrease caregiver burden once home. The Plan denied your 
request. The Plan says that an IRF level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary. Our physician reviewer found that you 
have complex functional impairments with neurological deficits and active comorbidities. You will require 
close neurological monitoring and intense therapy. You can tolerate intense therapy and require continued 
inpatient hospitalization during rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myopro orthotic device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-
matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 
Although records from the device manufacturer/vendor argue medical necessity of the requested device, 
records from the enrollee's actual treating provider do not clarify why the requested device is the most 
appropriate treatment for the enrollee's condition. In addition, provided records report left upper extremity 
spasticity which may be a contraindication to use of the device. 
 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 the Myopro orthotic device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to provide a positron emission tomography (pet) scan. 
 
You asked the Plan to provide a positron emission tomography (pet) scan. You say that the services requested 
are medically necessary. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 provide a positron emission tomography (pet) scan. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the request for 
PET of the brain for cognitive decline does not qualify as a symptom for PET per NCD guidelines. 
 
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 positron emission tomography (pet) scan have not been met. Therefore, we 
decided that the Plan does not have to provide a positron emission tomography (pet) scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 
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 Entyvio. Our reviewer says that 
Entyvio is not medically reasonable and necessary in this case. Our physician reviewer found that there is no 
indication that the enrollee has tried and failed the required drug. There is no indication that the Plan's required 
drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
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 would benefit from skilled nursing services due 
to your medical complexity. The Plan denied your request. The Plan says that you do not meet criteria for SNF 
care and can be treated in a lower level of care such as home health. 
 
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 clinical documentation shows that you experienced multiple hospital complications 
with medication changes and clinical status changes thus would require skilled nursing for assessment. Clinical 
documentation shows you have new functional impairments per evaluating therapists with recommendation for 
daily skilled therapy in SNF setting. From a practical matter, daily skilled services in a SNF are medically 
necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as you no longer need 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy treatment. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the medical necessity criteria for the requested 
continued physical therapy. 
 
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 the treatment. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The requested treatment is not medically reasonable or necessary. Our physician reviewer found that 
the enrollee has previously been treated with outpatient therapies and should be independent with a home 
exercise program. There is no documentation of a recent injury or decline in function. The additional therapy 
services are not an appropriate duration and frequency for treatment of the enrollees medical condition and 
therefore are not 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 treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued physical therapy treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor-controlled ankle foot system (L5973).  
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this exceeds the enrollee's needs and cannot be covered. 
 
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 the request for the L5973 Proprio K3 MPA feet exceeds the patient's medical needs. The 
documentation does not support that the patient's activities and functional need require a microprocessor foot 
over a mechanical foot. Additionally, the requested Proprio foot has features such as monitoring of step count 
through an app which exceed the patient's functional needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a microprocessor-controlled ankle foot system (L5973).
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 and their family disagree with the denial 
for admission to an IRF. 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 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 enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/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.