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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a SNF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the heart, without 
contrast material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve the CT scan and related services. You say that this imaging service is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 CT scan and related 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 patient is asymptomatic from a cardiovascular standpoint. 
Numerous studies have demonstrated that coronary artery calcium (CAC) scoring using ultrafast cardiac CT 
adds predictive value in assessing risk of coronary heart disease (CHD). In one study a score of zero was 
associated with a CHD risk of 1-6%, while a CAC score over 300 was associated with a risk of 13-26% 
(Budoff, 2018). Clinical studies have not, however, shown that CAC scoring adds value in clinical management 
of asymptomatic patients in whom risk factors are targeted.  Mamadu in 2014 examined whether CAC scoring in asymptomatic adults might have an effect on behavior 
modification, risk perception, and medication adherence. While CAC screening improved medication 
adherence, the impact of CAC scoring on behavioral and lifestyle factors, perception of CHD risk, and 
psychosocial effects was not statistically significant compared with baseline. In summary, current evidence 
showing that the use of CAC scores in clinical management of asymptomatic individuals leads to changes in 
patient management or in individual risk behaviors that improve cardiac outputs outcomes is limited and 
inconclusive.  Overall, there is insufficient support in the peer-reviewed literature demonstrating a significant 
benefit of CT imaging of the heart with quantitative evaluation of coronary calcium in guiding optimal 
management of this patient. As such, CT imaging of the heart without contrast material with quantitative 
evaluation of coronary calcium is considered experimental/investigational for the evaluation and management 
of this patient's medical 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 CT scan and related services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve computed tomography (CT) scan of the heart, without contrast material, 
with quantitative evaluation of coronary calcium (75571).
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 needs IRF care. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing 
skilled therapy and nursing needs can be provided at a lower 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. 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. The enrollee continues to have a need for skilled therapy 
with ongoing safety concerns and a potential for functional improvement however, the documentation doesnt 
support that he would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no 
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 
15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status. 
  
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 shoulder arthroscopy. 
 
You asked the Plan to pre-approve shoulder arthroscopy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 shoulder arthroscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, 
and comprehensive less invasive conservative care measures for the left shoulder. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the requested shoulder arthroscopy with distal claviculectomy 
including distal articular surface (Mumford procedure); extensive debridement; and decompression of 
subacromial space with partial acromioplasty with coracoacromial ligament release, in this case, 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 shoulder arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder arthroscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve consultation services. You say that this care is medically necessary. The 
Plan denied your request. The Plan says there are multiple in-network providers available to provide the 
medical care in question. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
consultation services to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services in your home (G0151 x 
6). 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the medical record does not document a clearly evident need for the 
services of a skilled physical therapist. 
 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 requested home health services are not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that the enrollee has documented, ongoing, home health physical 
therapy (PT) needs. The reviewer found that the enrollee is functioning at a level commiserate with a lower 
level of care. Therefore, the reviewer found that the requested, ongoing, home health PT services are not 
medically necessary or reasonable. 
 
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 physical therapy (PT) services in your home (G0151 x 6).
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you did not have any parental medications, 
complex wound care or nutrition given via a feeding tube. You were medically stable without any acute 
exacerbations of chronic medical problems. Your physical function was at or near your baseline. You were not 
expected to make measurable gains within a reasonable and predictable period of time or require skilled 
therapy to prevent deterioration with mobility or self-care tasks. You did not require skilled therapy to establish 
a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an 
inpatient basis, at a SNF level of care at the time of discharge from the hospital. 
 
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: 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 broke your hip and had to have a partial hip 
replacement. You say that you were completely independent before this and want this level of rehab to get you 
back to that level of independence. The Plan denied your request. The Plan says the complexity of your 
nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitative 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 you have no complex nursing or rehabilitation needs. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
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 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 pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not have documented evidence of lymphedema of the chest, trunk, or abdomen. The 
enrollee does not have documented unique characteristics that would indicate the segmented pump over a 
standard pump. There is no provided documentation of a trial and failure of the standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient rehabilitation facility (IRF) admission. 
 
You asked the Plan to pre-approve the IRF admission. You say that  The Plan denied your request. The Plan 
says that the IRF admission is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, there were no records provided to determine if the requested 
services were medically necessary. Therefore, we decided that the Plan has to pre-approve an inpatient 
rehabilitation facility (IRF) admission.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement. 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested Vertiflex spacer is considered experimental. More research is 
needed to show safety and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the spinal cord stimulator is 
medically necessary. The Plan denied your request. The Plan says a decision was not rendered within the 
allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial is subject to the criteria 
listed 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 for the spinal cord stimulator trial. Our reviewer says 
that the requested spinal cord stimulator is not medically reasonable and necessary. Our physician reviewer 
found that the criteria for a spinal cord stimulator have not been met per. The documentation is not clear that 
when the patient had prior physical therapy. There are no objective notes from physical therapy indicating 
objective outcome in terms of pain and function from this treatment for the lumbar spine. Additionally, the 
procedure documentation indicates that the patient has had an epidural injection on the same date that he had a 
facet injection. The documentation does not reveal outcome of the epidural injection in terms of objective pain 
improvement and objective functional outcome. The patient was rotated on Celebrex and Methocarbamol per 
the November 29, 2021, progress note and there no additional follow up visit indicating objective outcome in 
terms of pain improvement and function from these medications. The Medicare guidelines state patient should 
have careful screening including a psychological evaluation. The documentation does not support that the 
psychologist is aware of the patient's recent toxicology urine test revealing cocaine use therefore it is not clear 
that this was that thex patient was determined a "reasonably good candidate" per the psychologist however it 
does not appear the psychologist was aware of the cocaine on the urine drug test.   
 
 Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Nujolix. 
 
You asked the Plan to pre-approve Nulojix. You say that you would like reconsideration because the requested 
drug is medically necessary. The Plan denied your request. The Plan says that this drug is not being prescribed 
within medically-accepted standards. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Nulojix. Our reviewer says that the 
Medicare approved  drug compendia contains a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Our physician reviewer found the Food and Drug Administration has granted 
orphan drug designation to the requested drug for prophylaxis of organ rejection in renal allograft recipients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nulojix have been met. Therefore, we decided that the Plan has to pre-approve 
Nujolix.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) dental implant placements (D6010). 
 
You asked the Plan to pre-approve dental implants. You say that these services are necessary. The Plan denied 
your request. The Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve eight 
(8) dental implant placements (D6010).