Persius/hicric huggingface dataset:
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 does not meet 
criteria. 
 
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. Therapy services may be 
provided 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 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 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 documentation does not support that the complexity of your nursing, medical and 
rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The documentation does not support that you require at least 3 hours of therapy per day at least 5 days per 
week, or 15 hours over 7 consecutive days, of therapy services. It is not clear that you are reasonably expected 
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: 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 your physician states you need medical management 
and to be seen daily by a physician at rehab to reduce your risk of returning back to the hospital. You say that 
you wish to return to independent as quickly as possible and wish to receive rehabilitation at the rehabilitation 
hospital. The Plan denied your request. The Plan says you can safely receive the services you need in other 
settings.  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 complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation 
supports that services may be provided 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 a FreeStyle Libre 2 sensor and reader device. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor and reader device. You say that the enrollee is 
treated with one shot of insulin daily. You also say that the enrollee would benefit from a CGM with alarm 
features. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
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 injections. Based on this information, we decided that Medicare rules for coverage of 
the FreeStyle Libre 2 sensor and reader device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a FreeStyle Libre 2 sensor and reader device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 pre-approve Keytruda. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 67-
year-old male with bladder / left renal pelvis cancer. In this case, the requested use of Keytruda is not FDA-
approved for the enrollees diagnosis as there is prior progression of disease on this drug. In addition, the use of 
Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L300 Go Thigh Plus System (CPT code E0770) and 
durable medical equipment, miscellaneous (CPT code E1399). 
 
You asked the Plan to pre-approve the system. You say that the machine that is being requested has helped you 
beyond measure and you can walk with just a cane, the device is medically necessary since your condition is 
getting worse and this would also help with physical therapy (PT) since it forces your leg to work and can help 
with stimulating and strengthening muscles. The Plan denied your request. The Plan says this device is 
considered not medically necessary as a technique to improve function or to treat other conditions after nerve 
damage or nerve injury (e.g., post-stroke, multiple sclerosis ). 
 
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 system. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation indicates that the requested muscle stimulation ((E0770- Functional 
Electrical Stimulator; Bioness L300TM GoSystem) device does not meet the definition of medical necessity. 
This device is considered not medically necessary as a technique to improve function or to treat other 
conditions after nerve damage or nerve injury (e.g., post-stroke, multiple sclerosis). 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L300 Go Thigh Plus System (CPT code E0770) and durable medical equipment, 
miscellaneous (CPT code E1399).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a 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 you 
do meet the Medicare criteria for SNF care. Our physician reviewer found you do not have documented skilled 
nursing needs, though ongoing monitoring for alcohol withdrawal is reasonable. You do have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
Ongoing therapy to improve strength, endurance and adaptive techniques is necessary. Daily skilled services 
are required to establish a maintenance program and/or to prevent deterioration of your condition. You do 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lightweight portable power wheelchair 
(K0012) provided on August 25, 2021. 
 
You asked the Plan to waive the coinsurance for a lightweight portable power wheelchair. You say that the cost 
of the wheelchair at issue is $2,895 and that the Plan should pay 80% of this amount. The Plan denied your 
request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay $75.65, or 20% of the Medicare-allowed charge of $378.23, for a lightweight 
portable power wheelchair. A lightweight portable power wheelchair falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for a lightweight portable power wheelchair (K0012) provided on August 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B coverage criteria for Prolia. 
 
  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 Prolia. Our reviewer says that Prolia 
(J0897) is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
drug, Zoledronic Acid before they will approve the requested drug. Our reviewer found that in this case, the 
enrollee has not tried and failed the required drug. Our physician reviewer also found that there is no 
documentation provided indicating that the Plans required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the member has disabling pain that 
affects their quality of life and has failed non-operative treatment. You say that this procedure fills a treatment 
gap for patients that don't receive adequate relief from conservative methods and the procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is unproven and 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation is lacking regarding detailed or evidenced findings supportive 
of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit services provided from July 1, 2021, through 
September 30, 2021. 
 
You asked the Plan to pay for the home visit services. You say that the non-nursing services could be 
categorized as custodial care but there were other services provided by registered nurses. You say that those 
services should be covered. The Plan denied your request. The Plan says custodial care is not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home visit services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the home 
visit services provided from July 1, 2021, through September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G device. 
 
You asked the Plan to pre-approve a MyoPro 2 Motion G device. You say that the requested MyoPro 2 Motion 
G device is medically necessary. The Plan denied your request. The Plan says the requested MyoPro 2 Motion 
G device 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 a MyoPro 2 Motion G device. Our 
reviewer says that the requested MyoPro 2 Motion G device is not medically necessary. Our physician reviewer 
found based on the medical records provided there is no documentation that the MyoPro 2 Motion G device is 
medically reasonable and necessary for the enrollee in this case. Current clinical guidelines designate robotic 
therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" 
with unproven benefit in the home environment. Although records from the device vendor argue medical 
necessity of the requested device, no records from the enrollees actual treating provider clarify why the 
requested device is the most appropriate treatment for the enrollees condition. In addition, records document 
the enrollee has significant left upper extremity spasticity which is a contraindication to the 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 a MyoPro 2 Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro 2 Motion G device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Estradiol cream (J3490). 
 
You asked the Plan to pre-approve Estradiol cream. You say that the requested drug is medically necessary. 
The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says 
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare 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 Estradiol cream (J3490).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special cushion (L5668) and quick-change self-
alignment system (L5617) for a prosthetic leg. 
 
You asked the Plan to pre-approve a special cushion and quick-change self-alignment system. You say that the 
items are medically necessary. The Plan denied your request. The Plan says these items do 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 a special cushion (L5668) and quick-change 
self-alignment system (L5617) for a prosthetic leg.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve RFA services. You say that this treatment is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested RFA services are not 
considered 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 RFA services. 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 is a 72-year-old male with a history of lumbosacral spinal stenosis (status post 
epidural steroid injection and RFA) and a left foot Morton's neuroma, between 3rd and 4th digits.  He received 
a weekly injection in the lesion of the plantar nerve of his left foot x8 weeks. The member states he is in pain 
whenever he puts shoes and boots on.  His pain is rated 9/10 - 10/10.  The provider is requesting a Morton's 
neuroma radiofrequency ablation, left foot. 
 
Medical studies do not show that this procedure works better than others.  A literature search reveals a retrospective cohort study and a few case series to support this practice.  Medicare has not issued specific 
coverage criteria in the form of an LCD (Local Coverage Determination) or NCD (National Coverage 
Determination) for this particular item or service. However, per Social Security Act, Section 1862 (a)1(A) and 
the 42 CFR Section 411.15(k), Medicare does not pay for any items or services that are not reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 
member. A Morton's neuroma radiofrequency ablation is considered investigational and not a covered benefit. 
The requested procedure does not meet medical necessity for policy guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) services.