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

 
We decided that the Plan does not have to pre-approve the requested admission to inpatient psychiatric care. 
 
You asked the Plan to pre-approve the inpatient psychiatric admission. You say that it is felt that this level of 
care is necessary. The Plan denied your request. The Plan says the enrollee can be managed is a less restrictive 
setting. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric admission. Our 
reviewer says that the documentation does not support that the requested inpatient mental health services are 
medically reasonable and necessary. Our physician reviewer found at the time of admission, the enrollee is 
noted to be in no psychiatric distress and is eating and sleeping adequately. She is complaint with her 
medications. The progress notes do not indicate that the enrollee has been aggressive with peers or staff on the 
unit or has had any recent attempt or desire to harm herself. There is no indication in the available medical 
records that the enrollees psychiatric symptoms could not be managed on a less restrictive basis.  
 
The enrolleee did not express any active suicidal ideation or intent, or any intent to harm themselves or anyone 
else. She was not exhibiting any other significant symptoms such as psychosis or mania. She had no acute 
psychiatric issues that would require continued inpatient care. The enrollee has chronic symptoms. The 
available medical records do not support that continued inpatient care will change these symptoms or the 
current condition.   
 
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 inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the requested admission to inpatient psychiatric care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that medical nutrition therapy is 
medically necessary. The Plan denied your request. The Plan says medical nutrition therapy is not medically 
necessary. The member has no documented diagnosis of diabetes or chronic kidney disease. Medicare only 
covers nutritionist services for patients with diabetes or certain types of kidney disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (G0152, G0151). 
 
You asked the Plan to pre-approve home health services. You say that the services should be covered as 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 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
records in this case do not document that the enrollee is currently home bound and unable to leave the home for 
the outpatient therapy services that have been approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services (G0152, G0151).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sinuva. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has nasal polyps and has 
undergone septoplasty and turbinate reduction. The record does not indicate that the enrollee has undergone 
ethmoid sinus surgery. The Food and Drug Administration (FDA) has not indicated that the drug is approved 
for the enrollee's condition nor do the Medicare-approved drug compendia contain a supportive citation. Sinuva 
is 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 Sinuva.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve remote monitoring of blood pressure with MD watch. 
 
You asked the Plan to pre-approve remote monitoring of blood pressure with MD watch. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary.  
The Plan follows Medicare rules. Medicare rules say that remote blood pressure monitoring is only covered 
when the enrollee has white coat hypertension or suspected masked hypertension. 
 
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 remote monitoring of blood pressure 
with MD watch. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of essential 
hypertension. The documentation does not support that the enrollee has white coat hypertension. The 
documentation does not support that the enrollee has suspected masked hypertension. Therefore, the enrollee 
does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of remote monitoring of blood pressure with MD watch have not been met. 
Therefore, we decided that the Plan does not have to pre-approve remote monitoring of blood pressure with 
MD watch.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Reader continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. The Plan denied your request. The Plan says this 
item is not covered because the enrollee is not on insulin. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 Reader continuous 
glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve physical therapy services. You say that you cannot walk, and you are still in 
pain. The Plan denied your request. The Plan says the enrollee's records do not support the request for 
treatment. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee does not require ongoing skilled therapy 
beyond what was approved and should be able to transition to an independent home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided on July 29, 2022, billed with code 99223. 
 
You asked the Plan to pay for the EM services as billed. You say that this service was coded correctly. The 
Plan denied your request. The Plan says the code was 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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 EM code selected is not support in this case. Our reviewer found the enrollee is a 76-year-old male who 
was treated on 7/29/22. He presented to the hospital with abdominal pain, nausea, but no vomiting. He was 
found to have a small bowel obstruction and was treated with a nasogastric tube. He was identified as not 
having abdominal surgical history. The enrollee reported no acute distress, and physical findings were focused 
and unremarkable and normal. The pain resolved with initial treatment. Based on the provided documentation, 
there was insufficient evidence to show a comprehensive history or physical examination nor was there 
evidence of medical decision-making of high complexity.  
 
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 inpatient evaluation and management (EM) services provided on July 29, 
2022, billed with code 99223.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs for a Group 3 power wheelchair. 
 
You asked the Plan to pre-approve repairs. You say that the enrollee's current wheelchair needs to be modified 
to meet their current basic medical needs. The Plan denied your request. The Plan says the cost of the repair 
exceeds the cost of replacement. The Plan also says that the repairs are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs 
for a Group 3 power wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 10 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the 10 PT visits. You say that you feel that more therapy is required. The 
Plan denied your request. The Plan says continued PT is not medically necessary for you. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 10 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had prior therapy, and the documentation does not 
reveal that she requires the unique skills of a professional therapist to safely and effectively provide treatment, 
that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the enrollee's current condition or to prevent or slow further deterioration. The documentation notes the therapy 
is repetitive, and the enrollee's level of function does not require ongoing skilled 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 the 10 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional 10 physical therapy (PT) visits.
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 a home ventilator. You say that this equipment 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 a home ventilator. Our reviewer says 
that this device is not medically necessary. Our physician reviewer found the enrollee could be treated with a BiPAP machine with average volume-assured pressure support capability and failure of such a device has not 
been documented. 
 
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 (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avsola (Q5121). 
 You asked the Plan to pre-approve Avsola. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the preferred drugs, Remicade, Inflectra, infliximab, 
or Simponi Aria. 
 
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 Avsola. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs. The reviewer found that the documentation does not 
support that Remicade, Inflectra, infliximab, or Simponi Aria would likely be less effective, and/or would 
likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy 
criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avsola have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avsola (Q5121).
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 an IRF admission is recommended due to the 
member's current medical condition. The Plan denied your request. The Plan says the member does not meet 
the requirements for an 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve Mounjaro. You say that your primary provider selected Mounjaro as the 
best treatment to accomplish your weight loss to reduce your body mass index. The Plan denied your request. 
The Plan says Mounjaro is on the self-administered drug list and is excluded from coverage 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 Mounjaro.  
 
Benefits for Mounjaro 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure fills a treatment gap for 
those that do not receive adequate relief from traditional conservative methods and do not have instability to 
indicate the fusion is the appropriate treatment. You also say that the enrollee has tried and failed conservative 
treatment without relief. The Plan denied your request. The Plan says the requested procedure 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates scoliosis and foraminal stenosis. The reviewer found that there is no clear indication of the cause of the enrollee's back pain. Therefore, the reviewer found 
that the requested Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on May 
18, 2022. 
 
You asked the Plan to pay for the FoundationOne CDx testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the FoundationOne CDx testing have 
been met. Specifically, no medical records or literature was provided to support the service at issue. Only lab 
results were submitted. No office or clinical notes were provided to support medical necessity of this service. 
Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided 
on May 18, 2022.