Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA) 
procedure. 
 
You asked the Plan to pre-approve PTA procedure. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the enrollee does not have atherosclerotic obstructive lesions in 
the right leg. 
 
The Plan follows Medicare rules. Medicare rules state that PTA is only covered for specified indications. 
 
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 PTA procedure. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested PTA. Our physician reviewer found the 
enrollee has diagnoses of peripheral vascular disease and right leg pain. The record sent by the provider 
indicates the enrollee had left leg circulation problems. There is skin discoloration and pain in the calves with activity that improves with rest. The report says that there is "mild peripheral arterial disease in the right leg." 
The records state that the provider ordered a computed tomography angiography (CTA) of the abdomen and 
pelvis, but it was scheduled for November 25, 2022. There is no specific clinical rationale for the requested 
PTA. The review has determined that the enrollee does not meet the coverage indications for PTA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PTA procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous transluminal angioplasty (PTA) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Genvisc injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you did 
not have a good response to treatment in 2021. 
 
The Plan follows Medicare rules. Medicare rules say that Hyaluronan therapies are only covered under certain 
medical indications.  
 
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 you have osteoarthritis of the knees. The record provided indicates that you have 
previously received viscosupplementation injections. The records provided are insufficient to establish that the 
criteria for coverage are satisfied. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rule. Therefore, the requested service is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Genvisc injection.
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 has an infection and needs therapy. The 
Plan denied your request. The Plan says the enrollee does not need an intensive team for care. 
 
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 physician reviewer found 
that the enrollee is in his home receiving home health services for weakness and unstable gait after treatment in 
an acute hospital and a skilled nursing facility for a left hip fracture that was surgically repaired. He is weak, 
unsteady and deconditioned. 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 enrollees medical conditions 
appear stable on outpatient medications with no issues that appear to require a physicians evaluation three or 
more times per week in a hospital setting. There is no support in the documentation that the enrollee requires 
the intensive medical care and the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation 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 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 you are appealing the denial of admission. The Plan 
denied your request. The Plan says admission to the IRF was denied as not meeting 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
at an intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing 
safety concerns and a potential for functional improvement however, the documentation doesn't support that 
you would meet criteria for admission to an acute inpatient rehabilitation facility. You can receive further 
services at a lower 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an aluminum ramp (E1399). 
 
You asked the Plan to pre-approve an aluminum ramp. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
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 an aluminum ramp (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rexulti. 
 
You asked the Plan to pre-approve Rexulti. You say that the enrollee has tolerated Rexulti well with no adverse 
reactions. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 
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. Therefore, we decided that the Plan does not have to pre-approve Rexulti.  
 
 Benefits for Rexulti 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: 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 will require close monitoring of daily 
pump adjustments. The Plan denied your request. The Plan says the enrollee can receive services at another 
level of care. 
 
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 physician reviewer found 
that the enrollee does not require intensive rehabilitation. The primary purpose of the request is to continue a 
hospital stay to monitor response to Baclofen dosing.  An IRF admission is for intensive rehabilitation and not to continue monitoring an acute issue in absence of 
need for intensive therapy. The enrollee's functional issues are chronic and modest. Therefore, the request 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 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 Myopro. 
 
You asked the Plan to pre-approve Myopro. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested item 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 Myopro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has left upper extremity partial paralysis. There is insufficient literature in the peer 
reviewed publications to assess safety, efficacy, long term outcomes or patient management associated with the 
use of the MyoPro Orthosis for upper extremity paralysis/paresis from conditions such as the patient's brachial 
plexus injury, or other neuromuscular/neurological disease or injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myopro have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Myopro.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says you should seek alternate housing as 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. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service December 
14, 2021. 
 
You asked the Plan to pay for procedure code 88305. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this service was not billed in accordance 
with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure code 88305 is a physician pathology service which has both a professional component 
(PC) and a technical component. This service was not billed with modifier 26 to indicate that only the 
professional component payment is requested. This means that payment is requested for both the PC and TC of 
this service. However, this service was provided to an enrollee who was in an outpatient hospital setting at the 
time the sample was collected, which means that the TC component is bundled into the facility payment. The 
TC portion of this service is not separately payable, and therefore this service is not supported as billed. Based 
on this information, we decided that Medicare rules for coverage of procedure code 88305 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 88305 billed for date of service 
December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthosis. 
 
You asked the Plan to pre-approve the MyoPro orthosis. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro orthosis. 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, improve hemiparetic arm function, or be safe for long term use 
for this enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the requested CGM. You say that you need this CGM to better control your 
blood sugar levels. The Plan denied your request. The Plan says the criteria for the CGM are not 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 use insulin 
with at least three daily administrations. Based on this information, we decided that Medicare rules for coverage of the requested CGM have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Sprint peripheral nerve stimulator (PNS) 
device. 
 
You asked the Plan to pre-approve a Sprint PNS. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested service is experimental/investigational. 
 
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 Sprint PNS. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested modality for chronic pain management is still being studied to see if the treatment is as 
good as or better than standard treatment for chronic pain. There is insufficient medical literature to support the 
use of the Sprint PNS system for chronic hip pain. 
 
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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve placement of a Sprint PNS device.
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 every time he comes home he gets worse and he 
needs a physical therapy program to get him back on his feet again. The Plan denied your request. The Plan 
says ongoing skilled care can be provided in an alternative setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found you do require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours 
over seven consecutive days. Currently you require moderate assistance with bathing and toileting, minimal 
assistance with bed mobility and transfers, and contact guard assistance when ambulating 50 feet with a walker. 
You are receiving speech therapy for cognitive deficits and have difficulty with attention, awareness, and 
recall. You have had a significant functional decline from your baseline level of function and would benefit 
from the intensity of therapies provided on acute inpatient rehabilitation, including physical, occupational and 
speech therapies. You are noted to be able to participate in therapy and follow commands. Therefore, the acute 
inpatient rehabilitation admission is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 27, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
27, 2022.