Persius/hicric huggingface dataset:
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 would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the services they need in the current 
hospital setting. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The enrollee is receiving appropriate care at the present 
acute care hospital. 
 
   
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable for an 
admission to an LTACH. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee can receive the care they need in current hospital setting. 
 
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 There is no evidence that the enrollee requires services that are not currently 
available at their current acute setting. The enrollee can remain at the current acute care hospital until no acute 
services are required. The enrollee can then be 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 long term acute care hospital (LTACH) services.
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 requires daily physician 
management and cannot be adequately cared for in their current condition at a skilled nursing facility. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee is 
receiving the care they need in the current hospital setting. 
 
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 there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) for lung 
cancer screening. 
 
You asked the Plan to pre-approve an LDCT for lung cancer screening. 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 an LDCT for lung cancer screening is covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an LDCT for lung cancer screening. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has 
a 15 pack year smoking history having quit in 2013. In order to qualify for LDCT the history must include at 
least a 20 pack year smoking history and the enrollee must be asymptomatic with no imaging or clinical 
findings to suggest lung cancer. This enrollee has a history of multiple pulmonary nodules seen on computed 
tomography (CT) exams of 2016-2021. Thus, per CMS guidelines the enrollee does not qualify for a LDCT. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an LDCT for lung cancer screening have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a low dose computed tomography (LDCT) for lung cancer 
screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the 
enrollee was recently hospitalized with hepatic encephalopathy and acute hypercarbic respiratory failure, likely 
related to the encephalopathy, volume overload, and obesity-hypoventilation syndrome (OHS).  A diagnosis of 
chronic obstructive pulmonary disease (COPD) is mentioned in some places in the hospital record, but is not included in the discharge diagnoses, and is not supported elsewhere in the records. There are no pulmonary 
function tests. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. This enrollee may 
benefit from BiPAP during sleep as an outpatient. Medicare does not cover a home ventilator when used as 
BiPAP, or in the treatment of OHS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of spine (72148). 
 
You asked the Plan to pre-approve MRI. You say that the requested service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI of the lumbar spine is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate any red flags such as weakness. The reviewer found that there is no 
contraindication presented against a 6-week trial of supervised physical therapy. Therefore, the reviewer found 
that the requested MRI of the lumbar spine is not 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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of spine (72148).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an expandable 
controller (E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power 
tilt, recline and power elevating leg rests through the joystick. 
 
You asked the Plan to pre-approve a power seat elevation system (E2300), an expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick. You say that the requested power seat elevation system (E2300), 
expandable controller (E2377), expandable controller harness (E2313), and electronic connection (E2311) to 
control power tilt, recline and power elevating leg rests through the joystick are medically necessary. The Plan 
denied your request. The Plan says the requested power seat elevation system (E2300), expandable controller 
(E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick are 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 a power seat elevation system (E2300), 
an expandable controller (E2377), expandable controller harness (E2313), and electronic connection (E2311) to 
control power tilt, recline and power elevating leg rests through the joystick. Our reviewer says that the 
requested power seat elevation system (E2300), expandable controller (E2377), expandable controller harness 
(E2313), and electronic connection (E2311) to control power tilt, recline and power elevating leg rests through 
the joystick are not medically necessary. Our physician reviewer found based on the documentation provided, 
the enrollee has sufficient upper body strength and range of motion to manage standard switches for multiple 
power drives. 
 
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 power seat elevation system (E2300), an expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300), an expandable controller (E2377), expandable 
controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI), any joint of upper extremity 
(73221). 
 
You asked the Plan to pre-approve MRI. You say that you are concerned about a tendon rupture due to a lump 
and restricted motion of the enrollee's arm. You say that the radiology department advised that an ultrasound or 
x-ray would not show a tendon rupture. You also say that the MRI is medically necessary. The Plan denied 
your request. The Plan says that the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is medically necessary. Our physician reviewer found the provided documentation is highly 
suggestive of a "Popeye" deformity of biceps tendon rupture. While ultrasound may be useful in some 
orthopedic centers for evaluation, that technique requires familiarity and expertise which is not found in all x-
ray departments. The reviewer found that gold standard for imaging would be the requested MRI of the left 
shoulder. Therefore, the reviewer found that the requested MRI is medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI have been met. Therefore, we decided that the Plan has to pre-approve a 
magnetic resonance imaging (MRI), any joint of upper extremity (73221).  
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the patient does not meet criteria for coverage of SNF admission. 
 
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. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that patient has functional and clinical change, thus 
would require skilled nursing for assessment and skilled therapy. Evaluating therapists document that patient is 
unsafe for home discharge due to functional deficits and not all therapy goals have been reached, thus patient 
requires daily skilled services on an inpatient basis in a 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF 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 was admitted for chest pain and shortness of breath. 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, in 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) with accessories. 
 
You asked the Plan to pre-approve the wheelchair and accessories. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a power wheelchair and accessories are covered for 
the indications established in the applicable LCD.  
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 wheelchair and accessories. Our 
reviewer says that the requested wheelchair and accessories are not medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is not at high risk for skin breakdown and has intact skin. 
Additionally, she does not use a ventilator or require intermittent catheterization. 
 
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 wheelchair and accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a group 3 power wheelchair (K0861) with accessories.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria have 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 Evenity. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is an 80-
year-old female with a diagnosis of osteopenia and thoracic and lumbar compression fractures. The Plan 
requires a trial of drug(s) zoledronic acid or Prolia (denosumab) before they will approve the requested drug, 
Evenity. Based on the medical records provided, there is no indication that the enrollee has tried and failed the 
required drugs. In this case, there is no indication that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections under monitored 
anesthesia care (MAC) sedation to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve SI joint injections under MAC sedation to be provided by an OON provider. 
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 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 provider at issue in this case is not a network provider with the Plan. 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 under MAC sedation. Our reviewer says that the services 
are not medically necessary. Our physician reviewer found there is no indication for an OON facility. The 
enrollee has not had a trial of oral sedation prior to the procedure. There is no indication for separate anesthesia 
provider at this point. The enrollee is not taking anti-anxiety psychiatric medications. The requests 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 SI joint injections under MAC sedation have not been met.  
 
The Plan has network providers available who could have provided the items/services at issue in this appeal if 
the services had been deemed medically necessary. We found no exception that would require the Plan to pre-
approve SI joint injections under MAC sedation. Therefore, we decided that the Plan does not have to pre-
approve sacroiliac (SI) joint injections under monitored anesthesia care (MAC) sedation to be provided by an 
out-of-network (OON) provider.