Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve three-dimensional (3D) imaging. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that you 
do not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 requested services. Our physician 
reviewer found that a prostate magnetic resonance imaging (MRI) with MRI-directed biopsy of suspicious 
lesions is increasingly regarded as a valuable tool for refining risk status for clinically meaningful prostate 
cancer. Multiparametric MRI-directed biopsy is more sensitive than systematic transrectal ultrasound scan 
(TRUS)-guided biopsy alone for detecting clinically significant prostate cancers and reducing the number of 
clinically insignificant cancers diagnosed. Therefore, the service is reasonable and 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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve three-dimensional (3D) imaging.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the admission to a skilled nursing facility is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee can receive the 
care they need in another setting, such as home, a long-term care facility, or other outpatient setting. 
 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation does not support 
that the MyoPro Motion G orthotic is medically necessary for the enrollee. The records from the enrollee's 
actual treating provider do not clarify why the requested device is the most appropriate treatment for the 
enrollee's condition. In addition, provided records report left upper extremity spasticity which may be a 
contraindication to use of the device. 
 
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 a MyoPro Motion G orthotic.
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 necessary for the enrollee 
to receive the therapy services needed to regain strength and mobility. The Plan denied your request. The Plan 
says the services needed 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says admission is denied as not meeting 
IRF criteria, is not medically necessary, and a lower level of care might be appropriate. Skilled nursing facility 
level of care was offered. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
While the medical records support 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 the 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for transcutaneous electrical nerve stimulator (TENS) unit leads on August 
4, 2022. 
 You asked the Plan to pay for TENS supplies. You say that you are requesting payment for these supplies. The 
Plan denied your request. The Plan says that the services are not a covered benefit as there is no evidence to 
support the ordering provider is treating 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 record includes a valid order and proof of delivery for the billed items and 
the Plan has not provided any other rationale or evidence to support a denial. Therefore, we decided that the 
Plan has to pay for transcutaneous electrical nerve stimulator (TENS) unit leads on August 4, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a continuous glucose monitor (CGM). 
 
You asked the Plan to provide a continuous glucose monitor (CGM). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not . Based on 
this information, we decided that Medicare rules for coverage of a continuous glucose monitor (CGM) have not 
been met. Therefore, we decided that the Plan does not have to provide a continuous glucose monitor (CGM).
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 you 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's needs can be met at an alternate level of care. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The health plan has approved ongoing care in the current acute 
care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the RETACRIT (Q5106). 
 
You asked the Plan to pre-approve the RETACRIT. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says that the drug is 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 the RETACRIT. Our reviewer says that 
the member needs this medical item. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of anemia of chronic kidney disease and has required transfusion. The Food and Drug Administration 
has stated that the requested drug is indicated for the treatment of anemia due to chronic kidney disease, 
including patients on dialysis and not on dialysis to decrease the need for red blood cell transfusion. 
 
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 RETACRIT have been met. Therefore, we decided that the Plan has to pre-
approve the RETACRIT (Q5106).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional chiropractic manipulative treatments. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the requested 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 requested services are not medically necessary. Our physician reviewer found that in this case, the record 
indicates that the enrollee has low back pain from a subluxation of the spine. The records provided indicate that 
the enrollee has improved and is now receiving maintenance therapy, which is excluded by Medicare. The 
elements of the coverage criteria are not satisfied. The requested services are not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional chiropractic manipulative treatments.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says that this is not 
medically necessary.  
The Plan follows Medicare rules. Medicare rules say that Genomic Sequence Analysis Panels 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 genetic testing. Our reviewer says that 
the requested testing is not medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has a history of Hodgkin's Lymphoma with recent bone marrow aspirate positive for AML. The 
requested genetic testing is medically reasonable and necessary according to the coverage criteria established in 
the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve genetic testing.  
 
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 requested admission to an IRF 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 enrollee has been discharged from home therapy services. There is no indication 
for acute intensive therapy. 
 
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 ramp (E1399). 
 
You asked the Plan to pre-approve a ramp. You say that the enrollee needs the requested ramp to get out of the 
house. The enrollee cannot walk up or down the steps due to a surgery he had which has changed his way of 
life. The Plan denied your request. The Plan says the request is not medically necessary because the item is 
useful in the absence of disease, it would be used outside of the home, and it is not primarily medical in nature. 
 
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 ramp (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342 and 88360 billed for date of 
service February 25, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342 and 88360. You say that these services were 
reported correctly. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342 and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342 and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342 and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342 and 88360 billed for date of service February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81208, 81206, 81207 
provided August 15, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please reprocess the claim with the addition 
of medical records attached to support. The Plan denied your request. The Plan says This test is done for 
screening purposes and is not a Medicare benefit when done without documentation of medical indication from 
the treating provider. 
 
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 pay for the laboratory services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the services are not authorized because these tests are not a 
Medicare benefit when done without documentation of medical indication from the treating provider. The 
review has determined that the items/services at issue in this case are 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 81208, 81206, 81207 provided August 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued oxygen equipment services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request exceeds the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that oxygen equipment is only covered under certain 
medical equipment.   
 
We looked at the file and Medicare rules. The records show that 36 months of oxygen rental has been provided. 
The supplier who provided the equipment during the 36th rental month is required to continue to provide the 
equipment, accessories, contents (if applicable), maintenance, and repair of the oxygen equipment during the 5-
year reasonable useful lifetime of the equipment. Based on this information, we decided that Medicare rules for 
coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-
approve continued oxygen equipment services.