Persius/hicric huggingface dataset:
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 services are necessary, the enrollee has no help 
at home and is at risk for falls. The Plan denied your request. The Plan says the enrollee can receive therapies 
in home or in a long term care facility as outpatient service. 
 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 the provided records do not document the need for daily inpatient skilled therapy 
services. Records support that services in a setting such as an assisted living facility with home health care or in 
a long-term care facility on a part time basis are appropriate 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a StimQ peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is not supported for the treatment of your pain. 
 
The Plan follows Medicare rules. Medicare rules say that electrical nerve stimulators 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 ankle and foot pain. You have tried physical therapy, bracing, nerve blocks, and 
radiofrequency ablation. The request is for StimQ peripheral nerve stimulator of saphenous and superficial 
peroneal nerves. This is considered experimental/investigational therapy. Therefore, the request is deemed not 
medically reasonable and 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 not been met. Therefore, we decided that the Plan 
does not have to pre-approve a StimQ peripheral nerve stimulator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on August 12, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you have 
had similar services in the past that have never been denied and were not charged by the provider. The Plan 
denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 12, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on August 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the breast provided 
on May 25, 2022. 
 
You asked the Plan to pay for the MRI. You say that the MRI was medically necessary. The Plan denied your 
request. The Plan says the MRI was 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 pay for the MRI. Our reviewer says that the MRI of 
the breast is not medically necessary. Our physician reviewer found that the enrollee with bilateral breast 
prostheses had bilateral breast pain. No mammogram or ultrasound exams are noted in the records. No family 
or personal history of breast cancer. On the MRI report the breast tissue was described as almost entirely fatty. 
Absent any conventional imaging abnormality requiring clarification or genetic predisposition to breast cancer 
the medical necessity of the breast MRI done on May 25, 2022, has not been established in the records 
provided. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pay for a magnetic resonance imaging (MRI) of the breast provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 
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 HBOT is covered for specific indications only. 
 
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 a diabetic foot would 
with osteomyelitis. The records do not document failure of at least 30 days of treatment with standard wound 
therapy. The criteria for coverage are not met; therefore, HBOT 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 hyperbaric oxygen therapy (HBOT).
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's complex medical needs and the level of care an LTACH can offer are the absolute best course of 
treatment as they can be closely monitored by a team of daily physicians. You say that the enrollee requires a 
multidisciplinary approach for an extended amount of time and is medically stable for transfer. The Plan denied 
your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can safely 
receive the care they need in another 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 the enrollee is still unstable and requires short-term additional acute care hospital 
services that can be safely provided at the current facility until they are more appropriate for transfer. 
 
   
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the stimulator is approved for refractory 
overactive bladder. The Plan denied your request. The Plan says the records do not establish medical necessity. 
 The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is 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 the enrollee has an overactive bladder, nocturia, and urge incontinence. She performs 
intermittent self-catheterization, anticholinergic medication causes urinary retention, pelvic floor therapy has 
helped, and Myrbetriq works very well. Sacral nerve stimulator placement is not medical necessary in this case. 
The records show that the enrollee has had excellent results with pelvic floor therapy and Myrbetriq. Also, the 
records show that the enrollee has underlying neurological disease (multiple sclerosis) which excludes sacral 
nerve stimulator placement from coverage. Therefore, the request is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacral nerve stimulator.
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 you are in desperate need of acute inpatient care to 
receive physical and occupational therapy to help you walk again. The Plan denied your request. The Plan says 
your records do not show that you need an intensive team, medically necessary care may be provided safely in 
a different 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 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter tricuspid valve repair (TTVR). 
 
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 based on the current clinical guidelines, 
there is insufficient randomized clinical data at this time to support the use of TTVR in the setting of severe 
tricuspid regurgitation. As such, it would not be considered medically appropriate and necessary in this 
enrollee's management. 
 
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 transcatheter tricuspid valve repair (TTVR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infectious disease PCR (polymerase chain reaction) panel 
(87798, 87481, 87150) provided on May 25, 2022. 
 
You asked the Plan to pay for an infectious disease PCR panel. You say that this testing was medically 
necessary and reasonable. The Plan denied your request. The Plan says this testing was 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 pay for an infectious disease PCR panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee had a fungal infection of the left hallux nail. PCR 
infectious disease panel was requested. The standards for diagnosis and treatment of onychomycosis of the nail 
is to treat empirically if the appearance is suggestive of a fungal infection and if testing is warranted due to 
unclear clinical appearance, a culture and/or microscopic examination is standard of care and less expensive 
than PCR testing. Therefore, this request for PCR testing is not supported and will be considered 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 an infectious disease PCR panel have not been met. Therefore, we decided that 
the Plan does not have to pay for an infectious disease PCR (polymerase chain reaction) panel (87798, 87481, 
87150) provided on May 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Keytruda (J9271) and the administration (96413) 
provided on February 3, 2022. 
 
You asked the Plan to pay for the Keytruda and administration. You say that the enrollee has been on the same 
treatment since 2018, and this is a continuation of care. You also say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of continued 
treatment with Keytruda in the setting of disease progression and treatment beyond 24 months has not been 
demonstrated in the peer-reviewed medical literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pay for the Keytruda and administration. Our 
reviewer says that the Keytruda and administration were not medically reasonable and necessary for the 
enrollee. Our physician reviewer found the record indicates that the enrollee has a diagnosis of non-small cell 
lung carcinoma.  The record indicates that the enrollee has had disease progression and has received the 
requested drug for more than 24 months. Our reviewer found that the FDA has not stated that the requested 
drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from 
Medicare approved cancer journals were submitted for review. Our physician reviewer also found that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be 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 Keytruda and administration have not been met. Therefore, we decided that 
the Plan does not have to pay for the Keytruda (J9271) and the administration (96413) provided on February 3, 
2022.
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 without approval the enrollee can decline in health 
due to needing the rehabilitation to get strong enough to go home and live independent. The Plan denied your 
request. The Plan says the records do not show that the enrollee will be able to fully participate in and benefit 
from 3 hours of intensive daily therapies. Medically necessary care may be provided safely in a different 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 29, 2022 to 
September 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required NOA 
timely. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 29, 2022 to 
September 27, 2022.
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 it is medically necessary for the 
enrollee's care and meets the LTACH criteria for placement. The Plan denied your request. The Plan says the 
enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there 
are no issues for which LTACH may offer a therapeutic advantage. 
 
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 are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 
 
 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.