Persius/hicric huggingface dataset:
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 enrollee meets the full criteria for an IRF stay. 
The Plan denied your request. The Plan says the IRF services you are requesting 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our 
physician reviewer also found that there is not a reasonable expectation that this patient 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mycophenolate Mofetil 500 mg tablet. 
 
You asked the Plan to pre-approve Mycophenolate Mofetil. You say that this drug is medically necessary and 
reasonable. 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 as this drug is not being requested for a transplant. Therefore, we decided that the Plan does 
not have to pre-approve Mycophenolate Mofetil 500 mg tablet.  
 Benefits for Mycophenolate Mofetil 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional home occupational therapy visits. 
 
You asked the Plan to pre-approve 2 additional home occupational therapy visits. The Plan denied your 
request. The Plan says the medical record does not document a clearly evident need for the services of a skilled 
occupational therapist. 
  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 2 additional home occupational therapy 
visits. Our reviewer says that there is no documentation that additional skilled occupational therapy services 
beyond what have already been approved are required. Our physician reviewer found that the provided records 
document that you are largely independent with several activities of daily living and have been instructed in a 
home exercise program. The records do not document any acute or unstable medical conditions or changes in 
medication or treatment which would necessitate any further skilled occupational therapy visits.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 additional home occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 2 additional home occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardioversion (92960) and ECG (93010) provided on 
May 5, 2021. 
  You asked the Plan to pay for the cardioversion (92960) and ECG (93010). You say that medical records are 
enclosed, and the claim should be reconsidered for payment. The Plan denied your request. The Plan says an 
appropriate modifier was not billed with this code edit. 
 
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, we have confirmed that code 92960 
is a column II code to column I code 99291, and CPT code 93010 is a column II code to column I code 92960. 
This claim has not been billed with an appropriate modifier to bypass the edits. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the 
cardioversion (92960) and ECG (93010) provided on May 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HH SN services (CPT code G0299 x4). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 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 services. Our physician reviewer 
found the health plans denial should be upheld. You do not have documented skilled nursing needs.  As such, 
the requested, ongoing, HH SN services are not medically necessary or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve HH SN services (CPT code G0299 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652, E0667).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after February 11, 
2022. 
 
You asked the Plan to pre-approve SNF care after February 11, 2022. You say that the continued admission to 
a SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF 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 SNF care after February 11, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a 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 SNF care after February 11, 2022, have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care after February 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone. 
 
You asked the Plan to pre-approve Oxycodone. You say that the enrollee has tried and failed several 
medications. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition 
under Medicare 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 Oxycodone.  
 
 Benefits for Oxycodone 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 Solu-medrol for the enrollee. 
 
You asked the Plan to pre-approve Solu-medrol. You say that Solu-medrol is medically necessary. The Plan 
denied your request. The Plan says Solu-medrol is self-administered and therefore not covered under Medicare 
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 Solu-medrol for the 
enrollee.  
 Benefits for Solu-medrol 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 Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 29, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 29, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) services to be 
provided by a network facility. 
 
You asked the Plan to pre-approve the continuation of the SNF services. You say that the enrollee needs 
continued skilled care, as he is still on a feeding tube and catheter (with a diaper), and he needs physical 
therapy until he is able to regain his previous strength and nutrients to achieve the long-term goal of returning 
to his home. The Plan denied your request. The Plan says that authorization denied because the continuation of 
SNF services is not medically necessary, and you were provided at valid Notice of Medicare Non-Coverage 
(NOMNC). 
 
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. There were no records preceding the issuance of the Notice of Medicare Non-
Coverage (NOMNC) that have been submitted for review. Therefore, the health plan has failed to support it 
denial. Therefore, we decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) 
services to be provided by a network facility.  
 
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 Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the medication is 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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Keytruda. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the medication is not supported by 
compendia. Literature is case reports and cannot be used as the basis of approval. The medication is deemed 
experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
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 an intensive 
rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our 
physician reviewer also found that there is not a reasonable expectation that this patient 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs to be discharged with 
physical therapy and occupational therapy in order to gain back rehabilitation since her burns were pretty 
extensive. The Plan denied your request. The Plan says the SNF services you are requesting do not meet the 
requirements for approval. 
 
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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components and accessories, custom fabricated. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no actual records present from the treating physician or therapist that 
documented why this device is appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  
 Our physician reviewer found that the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. At this time, the requested robotic orthosis is not proven to be more beneficial for treatment 
of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy 
such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement 
therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not 
reasonable and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of 
a malformed body member. 
 
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 a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or 
double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management injections. 
 
You asked the Plan to pre-approve pain management injections. You say that pain management injections are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the Plan's Medical 
Policy: Comprehensive Musculoskeletal Management Guideline, CMM 203: Sacroiliac Joint Procedures. 
 
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 pain management injections. Our 
reviewer says that the requested pain management injections are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the criteria for the use of SIJ blocks include that the 
patient has had and failed at least 4-6 weeks of aggressive conservative therapy including, physical therapy 
(PT), home exercise, and medication management. There should be evidence of a clinical picture that is 
suggestive of sacroiliac injury and/or disease. At least three of the following positive exam findings of SI joint 
dysfunction should be present on physical exam such as: Patrick's test, thigh thrust, SI compression test, sacral 
thrust or Yeoman's test, SI joint compression test, or Gaenslan's test. The clinical value and effectiveness of an SI joint injection in the absence of tenderness and negative 
provocative testing results have not been demonstrated in the peer-reviewed literature. There is no 
documentation on physical examination of tenderness to the SI joint and no mention of SI provocative testing 
being completed with positive findings. The review has determined that the requested sacroiliac joint injection 
is not medically 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 pain management injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve pain management injections.