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

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you have 
improved to your baseline. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued inpatient care from March 21, 2022, forward was requested. 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 services. Our physician reviewer found that it was not expected 
you would improve in a reasonable period of time for the dates in question as you did not have suicidal or 
homicidal ideation noted or auditory or visual hallucinations.  It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient 
level of care rather than a lower level of care beyond the dates in question as you did not have dangerousness to 
self or others and were compliant with treatment. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for this admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has a past medical history of Parkinson's disease, spinal stenosis, and diabetes and is living at home with weakness and falls despite home health physical therapy. 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 this 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode (63650). 
 
You asked the Plan to pre-approve the percutaneous implantation of neurostimulator electrode (63650). You 
say that you plan to use the spinal cord stimulator to improve quality of life and minimize health care 
utilization including frequent office visits, procedures, and medication usage. You say that this patient has 
failed other treatment options and is a good candidate for spinal cord stimulators. The Plan denied your request. 
The Plan says the request does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the percutaneous implantation of 
neurostimulator electrode (63650). Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not yet 
exhausted all other treatment modalities for back pain. 
 
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 percutaneous implantation of neurostimulator electrode (63650) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous implantation of 
neurostimulator electrode (63650).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says that the criteria has not 
been met and the documentation does not show that it is medically necessary to make an exception for the 
enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable 2022 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pre-approve Prolia.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
colitis and diverticulitis after recent hip fracture. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the premium blood glucose test (A4253). 
 
You asked the Plan to pre-approve the premium blood glucose test. You say that the item is medically 
necessary. The Plan denied your request. The Plan says Plan preferred brands must be used. 
 The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the premium blood glucose test have not been met. Specifically, there is no indication as to why 
the requested brand is medically necessary over the Plan's preferred brand. Therefore, we decided that the Plan 
does not have to pre-approve the premium blood glucose test (A4253).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the CT scans. We decided that the Plan does not have to pre-
approve computed tomography (CT) abdomen and pelvis (74176).  
 
You asked the Plan to pre-approve the CT scans. You say that the medical records provided support the 
necessity of the services in dispute. The Plan says that the medical necessity criteria has not been met as the 
results of the prior study is needed that show the need for repeat imaging. 
 
We decided that the Plan has to pre-approve computed tomography (CT) thorax (71250).  
 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 scans. Our reviewer says that 
the requested items/services are considered partially medically reasonable and necessary in this case. Our 
physician reviewer found chest x-ray report of 1/12/22 describes an increase in prominence of the thoracic 
aorta and recommendation for CT of the chest for correlation. This exam is thus reasonable and indicated.  
There is a note that the enrollee was hospitalized 11/7/21 at which time a CT of the abdomen and pelvis was 
done which showed a stable small left hepatic lobe lesion unchanged since a prior exam (undated and no 
reports are in the records.)  Given the recent CT of the abdomen and pelvis and stated stability of the liver since 
a prior exam the justification for repeat CT of the abdomen and pelvis has not been explained by the requesting 
physician.  Again, the CT reports of prior exams have not been included in 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 the CT scans have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) thorax (71250).  
 
We also decided that the Plan does not have to pre-approve computed tomography (CT) abdomen and 
pelvis (74176). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computed tomography (CT) abdomen and pelvis (74176) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) abdomen and 
pelvis (74176). 
 
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: 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. The Plan denied your request. The Plan says your rehabilitation 
needs are not complex. 
 
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 physician reviewer found 
that you have a past medical history of diabetes, diabetic polyneuropathy, and obesity. You are living at home 
with weakness and falls. The complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for IRF admission and services provided from  
November 11, 2021, through November 23, 2021. 
 
You asked the Plan to pay for IRF care. You say that the IRF services were medically necessary. The Plan 
denied your request. The Plan says the IRF admission was 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 pay for 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 was medically stable and did not need physical medicine & 
rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. The enrollee was at the low functional level at the 
time of referral to IRF and it was unlikely that he would make a significant recovery in the predicted 7-14 days 
in an IRF. He needed a prolonged skilled nursing facility (SNF) stay to improve. The enrollee did not need 
intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. The IRF admission was not medically necessary based 
on medical stability, medical complexity, lack of acute rehabilitation nursing needs and low functional level.  
The enrollee's rehabilitation needs were at a lower intensity and at an alternate setting such as in an SNF. 
 
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 pay for IRF admission and services provided from November 11, 2021, through November 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the imaging findings do not correlate with the clinical complaints. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no correlation between physical exam and imaging showing compression of the nerve roots. 
There is no spinal instability. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara device. 
 
You asked the Plan to pre-approve a Volara device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the relatively expensive Volara, is convenient but not medically needed. 
Each DME component, the positive expiratory pressure device (E0601), the high frequency chest wall 
oscillator (E0483), and the nebulizer (E0570) can be approved separately 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Volara device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuromuscular stimulator, electronic shock unit 
(NMES) (E0745). 
 
You asked the Plan to pre-approve a neuromuscular stimulator, electronic shock unit. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the documentation submitted indicates your 
muscle loss was caused by a nerve problem is you spine. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of NMES to treat muscle atrophy is 
limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal 
cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a neuromuscular stimulator, electronic shock unit have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a neuromuscular stimulator, electronic shock unit (NMES) (E0745).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the 
enrollee has suffered from this condition for several years and has failed more than 5 months of conservative 
approaches to treatment. You say that this treatment is considered safe and effective, and the request should be 
approved. The Plan denied your request. The Plan says Medicare does not cover experimental and 
investigational services. 
 
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 insertion of stabilization device 
(22869 and 22870). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that interspinous process stabilization 
devices are experimental. More research is needed to show safety and efficacy.  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 insertion of stabilization device (22869 and 22870) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 
and 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections. 
 
You asked the Plan to pre-approve SI joint injections. You say that the enrollee has been 100% pain free since 
the previous injections. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because the enrollee underwent SI joint injections on March 2, 2022, and there must be at least 2 
months since the prior injection before repeat injections can be given. 
 
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 SI joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found SI joint injections can be repeated if the prior injection provided at least 75% pain 
relief for a period of at least 2 months. In this case, it has only been 2 weeks since the prior injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sacroiliac (SI) joint injections.