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

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from physical, 
occupational, and speech therapy, daily labs with close renal monitoring, and daily medical doctor rounding. 
The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care, such as in 
a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital for 
osteomyelitis of the toe. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires 
services that are not currently available. The enrollee can remain at the current facility until such time no acute 
services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing 
long term care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple procedures on the left leg tibial arteries 
including angioplasty, atherectomy, or stents. 
 
You asked the Plan to pre-approve multiple procedures on the left leg tibial arteries. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 multiple procedures on the left leg tibial 
arteries. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not support the medical necessity 
of the treatments in question. The enrollee has a history of back pain, back surgery, and left leg pain. There is 
no documentation of significant symptoms on the right. There is documentation of normal pedal pulses and 
documentation of normal arterial perfusion to the left lower extremity on an ankle brachial index (ABI) study 
that did not worsen with exercise. There is no documentation suggesting limb threat. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of multiple procedures on the left leg tibial arteries have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple procedures on the left leg tibial arteries 
including angioplasty, atherectomy, or stents.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation of cardiac rhythm monitor system provided on 
October 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for evaluation of cardiac rhythm monitor system. You say that the services were 
medically necessary. The Plan denied your request. The Plan says there was no prior authorization on file for 
these services. 
 
 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an evaluation of cardiac rhythm monitor system 
provided on October 6, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's acute needs have been met 
and stabilized in the acute care setting. You say that they are stable enough to transfer to an LTACH for the 
continuation of care in the long-term acute care setting. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee care can be provided in the current inpatient 
hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has ongoing acute medical issues and still requires acute care 
services.  The enrollee continues to receive acute care services, and these have not been denied.  The medical 
record does not indicate that the enrollee requires services that they are not currently receiving but that would 
be available at the LTACH facility. The elements of the coverage rules are not satisfied.  The requested service 
cannot be 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 not strong enough to go to outpatient. You 
say that you have a feeding tube and are wheelchair bound. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and your needs may be safely met at an alternate 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy. 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found certainly using ultrasound on a daily basis is not unreasonable, but to 
bill for daily simple simulations and/or Image-guided radiation therapy (IGRT) for a technology for which need 
has not been established by published data or supported by consensus guidelines. Billing for daily simulations 
or IGRT would not be furnished in accordance with 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 ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy.
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 that the enrollee was independent with mobility prior 
to admission to the acute care hospital. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee can safely receive the services they need in another setting. 
 
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 enrollees 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Botox. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no evidence that the enrollee is 
allergic to or intolerant of these other forms of medication. There is no evidence that the enrollee has tried and 
not responded to these other forms of medication. There is no documentation as to why these other forms of 
medication would not be expected to be safe and effective for the enrollee. Therefore, the requested Botox is 
not shown to be currently medically necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the lodging expenses related to your 
transplant incurred from June 18, 2022, through July 17, 2022. 
 
You asked the Plan to provide reimbursement for the transplant-related lodging expenses. You say that you live 
an hour away from the transplant center and were told that you needed to stay within 15 minutes of the facility. 
You feel that the Plan should cover the cost of this lodging. The Plan denied your request. The Plan says you 
do not met criteria for coverage of these costs as the facility was less than 50 miles from your home. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans are required to cover 
transportation/lodging expenses related to transplants only when the network provider for such services is 
located outside of the usual patterns of care for your area. The contract with the Plan also indicates this.  
 
We looked at the file and Medicare rules. As this transplant center was within 50 miles and one hour from your 
home, we find it is not outside the usual patterns of care for the distance travelled by Original Medicare 
beneficiaries in your area. Based on this information, we decided that Medicare rules for coverage of the transplant-related lodging expenses have not been met. Therefore, we decided that the Plan does not have to 
provide reimbursement for the lodging expenses related to your transplant incurred from June 18, 2022, 
through July 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is the subject of ongoing clinical trials and is considered experimental 
investigational at this time. Therefore, the request is deemed not medically reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
records document that the enrollee's wound is healing and is smaller in size. Thus, she has not failed an 
adequate course of standard wound therapy. Additionally she has not had adequate treatment of her significant 
peripheral vascular disease. The review has determined that the enrollee does not meet the coverage criteria 
detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision (99183).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous angioplasty (PTA) and stent placement 
procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not have symptomatic carotid artery stenosis greater than or equal to 70%. 
 
The Plan follows Medicare rules. Medicare rules say that a percutaneous transluminal angioplasty is only 
covered under certain medical indications. 
 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 services. Our physician 
reviewer found that the enrollee has bilateral carotid artery disease and previous right endarterectomy. The 
request is for a percutaneous angioplasty and stent placement in the left carotid artery. However, the enrollee 
has been asymptomatic. As such, this invasive procedure would not be considered medically appropriate and 
necessary in this enrollees management.  
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous angioplasty (PTA) and stent placement procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs cannot be met at a 
lower level of care. The Plan denied your request. The Plan says based on Medicare guidelines the long term 
acute care hospital services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and more stable and should only require short-
term additional acute care services that can safely be provided at the current facility until more appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where they are currently receiving care. Transfer to the LTACH is not medically necessary as it would 
not be clinically advantageous at this time. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle libre. 
 
You asked the Plan to pre-approve a Freestyle libre. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle libre have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle libre.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 17, 2022, 
through March 18, 2022. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary 
and billed correctly. The Plan denied your request. The Plan says the admission date reported on the claim is 
not appropriate per billing rules. 
 
The Plan must follow Medicare rules. Medicare rules say that for home health services continuing into 2022, 
the HHA must submit an NOA with an admission date for the first period of care in 2022. This admission date 
should be reported on all subsequent claims. 
 We looked at the file and Medicare rules. We find that the claim for these services did not report the admission 
date from the NOA filed in January 2022, as required. Based on this information, we decided that Medicare 
rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not 
have to pay for the home health services provided from February 17, 2022, through March 18, 2022.