Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options, and accessories including a power seat elevation feature, gel pads, joystick mount, and medical 
necessities bag. 
 
You asked the Plan to pre-approve a power seat elevation feature, gel pads, joystick mount, and medical 
necessities bag. You say that the requested features and items are medically necessary for the enrollee. The 
Plan denied your request. The Plan says that a seat elevation feature, gel pads and medical necessities bag do 
not serve a primary medical purpose. The Plan also says that the joystick mount is denied as unbundled.  
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
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 Group 3 power wheelchair with multiple power options, 
and accessories including a power seat elevation feature, gel pads, joystick mount, and medical necessities bag.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this device is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the home ventilator. Our reviewer says 
that the requested ventilator is not medically necessary. Our physician reviewer found the documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for weakness and third-degree heart block and had a pacemaker inserted. The enrollee was 
transferred to skilled nursing on 322/23 then discharged home on 4/11/23 where there is ongoing weakness. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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 insertion of interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve the device. You say that the requested treatment is considered safe and 
effective. The Plan denied your request. The Plan says the requested treatment 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 device. Our reviewer says that the 
requested insertion of interlaminar/interspinous process stabilization/distraction device is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the requested interspinous 
process distraction devices are considered experimental as more research is needed. Therefore, the reviewer 
found that the requested device 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nuclear medicine test. 
 You asked the Plan to pre-approve a nuclear medicine test. 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 the single photon emission computed tomograph 
(SPECT) acquires information on the concentration of radionuclides introduced into the patient's body. 
 
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 nuclear medicine test. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the documentation did not 
report considering essential tremor (ET) as on the differential. There was no mention of how test results would 
change treatment for this enrollee. There were no other clinical indications listed in the NCD to justify this 
testing. 
 
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 nuclear medicine test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a nuclear medicine test.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve SNF services. You say that the member is below baseline with room for 
improvement with consistent physical therapy. The Plan denied your request. The Plan says services requested 
can be received 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 
SNF services to be provided by an out-of-network (OON) provider.
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 member requires acute rehabilitation now and not 
in 30 days. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital evaluation and management (EM) 
services provided on September 6, 2022, billed with code 99205. 
 
You asked the Plan to pay for the EM services as billed. You say that the billed code is appropriate. The Plan 
denied your request. The Plan says the code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99205 is Office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the EM services as billed. Our reviewer says 
that the record does not support the billed code. Our reviewer found a consultation was provided to the enrollee 
while she was in the emergency department (ED). The ED physician had already identified the enrollees 
pelvic fractures. The consultant's medical decision making was not of high complexity. As such, the billing of 
CPT 99205 is not supported. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the outpatient hospital evaluation and management (EM) services provided on 
September 6, 2022, billed with code 99205.
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 services are medically and physically necessary 
for the enrollee to receive the services needed. The Plan denied your request. The Plan says the services the 
enrollee needs can be provided safely in another setting such as a skilled nursing facility, home with home 
health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are improving but still require additional 
rehabilitation. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you 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 or occupational therapy, there is no documented need for intensive rehabilitation services. 
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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve nerve block. You say that you want to appeal this denial. The Plan denied 
your request. The Plan says the requested injection 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 nerve block. Our reviewer says that the 
requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. Therefore, the reviewer found that the requested genicular nerve block is not reasonable 
or 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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in severe pain from your hip being broke and 
the sooner you get inpatient rehab the sooner you can get home. The Plan denied your request. The Plan says 
you can reasonably be expected to continue your recovery at a lower level of care with good success. 
 
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 you do not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard solution. 
 
You asked the Plan to pre-approve Gammagard solution. 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 off-label indications for intravenous immune globulin 
(IVIG) products will be considered medically reasonable and necessary in certain situations. 
 
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 Gammagard solution. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is no medical evidence 
of autoimmune diseases, no monoclonal gammopathy, no Guillen Barre Syndrome, no Myasthenia Gravis, no 
Eaton Lambert Syndrome, no Histocompatibility ABO, no allopath bone marrow, or Multiple Myeloma. There 
is no clinical rationale for the requested Gammmagard. The review has determined that the enrollee does not 
meet the coverage criteria detailed in the LCD for the use Gammagard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard solution have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Gammagard solution.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tretinoin 0.1% topical cream. 
 
You asked the Plan to pre-approve Tretinoin 0.1% topical cream. The Plan denied your request. The Plan says 
Tretinoin 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 Tretinoin 0.1% topical 
cream.  
 
Benefits for Tretinoin 0.1% topical cream 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durysta. 
 
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. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
glaucoma. The records are insufficient to establish the presence of elevated intraocular pressure or ocular 
hypertension. The Food and Drug Administration (FDA) has not stated that the requested drug is approved for 
the enrollee's condition and the Medicare-approved drug compendia do not contain a supportive citation for its 
use. The Durysta is therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Durysta.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says this request of 
Ondansetron for nausea and vomiting related to pain falls under Part D, and is not covered under Part B. 
 
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 Ondansetron.   
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.