Persius/hicric huggingface dataset:
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 services are medically necessary. The Plan denied 
your request. The Plan says your needs can be met at a lower level of care such as skilled nursing facility 
(SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this is medically necessary. The 
Plan denied your request. The Plan says that the records do not show this is a last resort. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators may be covered as therapy for 
relief of chronic intractable pain, provided that the conditions listed in the rules section 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 a spinal cord stimulator trial. Our 
reviewer says that the requested spinal cord stimulator trial is medically necessary. Our physician reviewer 
found the record shows that the enrollee has failed conservative management of the pain with narcotic and anti-
depressant pain medications, physical therapy, a home stretching/exercise program, and multiple injections. 
She has had four back surgeries and was told she was not a candidate for further surgery. She also takes over 
the counter medications and was cleared for this procedure by a mental health professional. 
 
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 spinal cord stimulator trial have been met. Therefore, we decided that the Plan 
has to pre-approve a spinal cord stimulator trial.  
 
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 NM Radioelement Handling. 
 
You asked the Plan to pre-approve NM Radioelement Handling. You say that the services are necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 NM Radioelement Handling. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found NCCN guidelines state that liver directed therapies are preferred over systemic 
therapy for unresectable disease. In general, every effort to maintain tumor control using liver directed 
therapies can be considered appropriate and within accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NM Radioelement Handling have been met. Therefore, we decided that the Plan 
has to pre-approve NM Radioelement Handling.  
 
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 Eliquis tablets. 
 
You asked the Plan to pre-approve Eliquis. You say that this is necessary. The Plan denied your request. The 
Plan says this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
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 Eliquis tablets.  
 
Benefits for Eliquis 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 pre-approve a bioimpedance spectroscopy (BIS), extracellular fluid 
analysis for lymphedema assessment (93702). 
 
You asked the Plan to pre-approve the BIS assessment. You say that this procedure is needed. The Plan denied 
your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the BIS assessment. Our reviewer says 
that the requested BIS assessment is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered experimental. The reviewer found that there is 
not enough research to support this method for routine clinical use. Therefore, the reviewer found that the BIS 
assessment is 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 BIS assessment have not been met. Therefore, we decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema 
assessment (93702).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was admitted for myocardial infarction and congestive heart failure. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. 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. There is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroplasty surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve knee surgery. You say that you feel you need this surgery as soon as 
possible. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this provider is out-of-network with the Plan and you can be treated by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
knee arthroplasty surgery to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says you could be treated with a continuous positive airway pressure (CPAP) or bilevel 
positive airway pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the requested home ventilator is not medically necessary. Our physician reviewer found the record shows 
that you may have obesity-hypoventilation syndrome. Continuous positive airway pressure (CPAP) or bilevel 
positive airway pressure (BiPAP) are more appropriate treatments. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve block procedure (64454). 
 
You asked the Plan to pre-approve the nerve block procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure is experimental and non-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 nerve block procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the role of genicular nerve blocks in the treatment of osteoarthritis is still being 
evaluated. It is considered experimental at this time. 
 
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 nerve block procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a nerve block procedure (64454).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography of the abdominal 
aorta and bilateral iliofemoral lower extremity runoff (code 75635). 
 
You asked the Plan to pre-approve a computed tomographic angiography of the abdominal aorta and bilateral 
iliofemoral lower extremity runoff. You say that a computed tomographic angiography of the abdominal aorta 
and bilateral iliofemoral lower extremity runoff is medically necessary. The Plan denied your request. The Plan 
says a computed tomographic angiography of the abdominal aorta and bilateral iliofemoral lower extremity 
runoff is not medically necessary and does not meet the Plan's Medical Policy criteria. 
 
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 a computed tomographic angiography 
of the abdominal aorta and bilateral iliofemoral lower extremity runoff. Our reviewer says that the requested 
computed tomographic angiography of the abdominal aorta and bilateral iliofemoral lower extremity runoff is 
not considered medically reasonable and necessary in this case. Our physician reviewer found that the 
documentation does not confirm sufficient severity as demonstrated by non-invasive studies or by unresponsiveness of symptoms to a course of medical therapy. As such, there is no evidence to suggest a need 
to perform a CTA of abdominal aorta and bilateral iliofemoral lower extremity runoff. In summary, there is 
insufficient documentation to support the medical necessity for CTA abdominal aorta and bilateral iliofemoral 
lower extremity runoff. 
 
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 computed tomographic angiography of the abdominal aorta and bilateral 
iliofemoral lower extremity runoff have not been met. Therefore, we decided that the Plan does not have to pre-
approve a computed tomographic angiography of the abdominal aorta and bilateral iliofemoral lower extremity 
runoff (code 75635).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography; sleep staging with 4 or more 
additional parameters of sleep, attended by a technologist. (CPT 95810). 
 
You asked the Plan to pre-approve a polysomnography. The Plan denied your request. The Plan says the 
requested Polysomnography 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 a polysomnography. Our reviewer says 
that a polysomnography is not medically necessary. Our physician reviewer found that in this case there was no 
documentation in the notes provided for review of a "Sleep history and symptoms including, but not limited to, 
snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches". 
 In the absence of documentation of such symptoms, it cannot be independently determined that the requested 
service would otherwise be reasonable and necessary for the enrollee at this time. Therefore the request would 
not be eligible 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 a polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a polysomnography; sleep staging with 4 or more additional parameters of sleep, 
attended by a technologist. (CPT 95810).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you prefer to continue receiving daily 
skilled care and therapies in the current facility rather than be transferred to the long-term custodial care unit. 
The Plan denied your request. The Plan says continued SNF care 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 continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found you appear to have reached a plateau in function. 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. Our reviewer also found that you do not require daily skilled nursing and/or 
skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high frequency chest wall oscillation system (vest 
system) (HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no computed tomography (CT) scans to show bronchiectasis. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a HFCWOD. Our reviewer says that the 
requested system is not medically reasonable or necessary. Our physician reviewer found that a high-frequency 
chest wall oscillation device is not medically necessary.  This patient has chronic obstructive pulmonary disease (COPD), but not cystic fibrosis, bronchiectasis, or neuromuscular disease. HFCWO has not been shown 
to be beneficial in the treatment of COPD, and Medicare does not cover it for that diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve high frequency chest wall oscillation system (vest system) (HFCWOD).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis. 
 
You asked the Plan to pre-approve Restasis. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
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 Restasis.  
 
Benefits for Restasis 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 25, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contractual agreement with the dialysis facility for payment. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested items. 
 
Medicare rules state that therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all 
criteria are met. The Plan follows these same rules.   
 
The records submitted in this case file are not from a certifying physician that has documented the enrollees 
diabetic condition. A Certifying Physician is defined as a Doctor of Medicine (M.D.) or a Doctor of Osteopathy 
(D.O.) who is responsible for diagnosing and treating the enrollees diabetic systemic condition through a 
comprehensive plan of care. The certifying physician may not be a podiatrist or clinical nurse specialist. 
Without this information, the enrollee does not meet Medicare criteria for coverage of the requested items. 
Therefore, we decided that the Plan does not have to pre-approve foot orthotics.