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 as the enrollee still 
requires care and would be unable to do the stairs in their home. The Plan denied your request. The Plan says 
the medical records submitted do not establish that the SNF continued stay is reasonable and 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurosurgery office visit (99213) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that this service is medically necessary. The Plan 
denied your request. The Plan says there are network providers available that can provide this service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
neurosurgery office visit (99213) to be provided by an out-of-network (OON) provider.
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 requesting reconsideration of the IRF 
admission. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 is functioning at a home care level and there is no indication for frequent 
physiatry oversight.  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: 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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for admission to the 
LTACH have not been met. 
 
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 the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (64483, 64484). 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request 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 epidural steroid injections. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is a lack of documentation in the case record of the degree of pain 
relief with prior treatment. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (64483, 64484).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve revascularization. 
 
You asked the Plan to pre-approve revascularization. You say that the services are necessary. The Plan denied 
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pre-approve revascularization. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation supports the appropriateness and medical necessity of the procedure in 
question. It is less likely that the enrollee's conditions will improve with conservative treatment, and 
endovascular treatment of common iliac artery stenosis has been shown to be more effective and durable as 
compared to treatment of the more common superficial femoral artery disease. Therefore, recommend coverage 
as the treatment plan is focused, symptom specific, appropriate, and 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 revascularization have been met. Therefore, we decided that the Plan has to pre-
approve revascularization.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the request 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 that the complexity of the enrollees nursing medical and rehabilitation needs does require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee would benefit from 
the oversight of a rehabilitation physician in the acute inpatient rehabilitation setting. The enrollee does 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. 
 
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 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure codes E2300, E2311, E2313, and E2377. 
 
You asked the Plan to pre-approve procedure codes E2300, E2311, E2313, and E2377. You say that the power 
functions are medically necessary for the enrollee. The Plan denied your request. The Plan says there is not a 
medical need to control the two approved power options through the joystick. The Plan also says there is no 
medical need for the power seat elevation. 
 
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 procedure codes E2300, E2311, E2313, 
and E2377. Our reviewer says that the requested upgraded electrical is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided records document that the enrollee has full 
range of motion of the arms, and 3/5 bilateral upper extremity strength. The documentation indicates the 
enrollee is independent with eating, thus indicating adequate upper extremity strength and function to operate 
the wheelchair's power options with their own switches. Therefore, the reviewer found that the request for 
upgraded electrical 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 procedure codes E2300, E2311, E2313, and E2377 have not been met. 
Additionally, procedure code E2300 is non-covered because they are not primarily medical in nature. 
Therefore, we decided that the Plan does not have to pre-approve procedure codes E2300, E2311, E2313, and 
E2377.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hematology/oncology consultation at the tertiary level 
of care. 
 You asked the Plan to pre-approve tertiary level consultation. You say that the community level physicians do 
not have the specific treatment you need. The Plan denied your request. The Plan says you do not meet criteria 
for tertiary level of care and can be treated at the community level. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 tertiary level consultation. Our reviewer 
says that you do not meet criteria for treatment at the tertiary level of care. Our physician reviewer found the 
Plan is offering adequate care to meet your needs through referral to a community level provider. There is not 
anything unique about your condition that would make it medically necessary for you to see the requested 
tertiary level provider. The Plan has community level providers who meet the standards of care required for 
treatment of your 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 tertiary level consultation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hematology/oncology consultation at the tertiary level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. The Plan denied your request. 
The Plan says you do not require insulin three or more times daily. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Xgeva (J0897). 
 
You asked the Plan to pre-approve Xgeva. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 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 Xgeva. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Alendronate, Ibandronate, Pamidronate, Risedronate and/or Zoledronic Acid 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required 
drugs. There is no documentation provided indicating that the Plans required drugs 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Xgeva (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a body-powered prosthetic thumb. 
 
You asked the Plan to pre-approve a body-powered prosthetic thumb. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the request 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 body-powered prosthetic thumb. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the available documentation does not reveal objective physician progress notes 
that indicate the medical necessity of the above device over a restorative prosthetic. The documentation notes 
the enrollee has numbness, weakness and tingling, but it is not clear whether these are a result of the 
amputation or enrollee has another underlying condition contributing to these symptoms. 
 
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 body-powered prosthetic thumb have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a body-powered prosthetic thumb.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electroencephalogram (EEG), continuous recording, 
administered in person by EEG technologist, minimum of 8 channels (95700) and video electroencephalogram 
(VEEG), review of data, technical description by EEG technologist, with continuous, real-time monitoring and 
maintenance, each increment of 12-26 hours (95716) 
 
You asked the Plan to pre-approve an EEG and VEEG. You say that the enrollee's current medical diagnosis 
requires this procedure to help with treatment. The Plan denied your request. The Plan says under the Medicare 
rules the request for video EEG monitoring is not medically necessary because the documentation does not 
support the need for an alternative evaluation or further evaluation because the diagnosis is in question of 
medications require adjustment. 
 
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 an EEG and VEEG. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case the most recent clinical documentation provided for review indicated 
that the enrollee had been seizure free since May 2022. The enrollee reported no breakthrough seizures as of 
November 2022, and condition is stable. A video shared at the time of that consult otherwise was not 
suggestive of epileptic activity. Given that the enrollees condition was said to have been stable, it is unclear 
why the requested inpatient EEG had been ordered. Such testing at this interval would otherwise exceed the 
enrollees clinical needs. It would not be the most appropriate service which could be provided to the enrollee 
at this time either. In as much it would not meet the Medicare definition of medical necessity. 
 
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 EEG and VEEG have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an electroencephalogram (EEG), continuous recording, administered in person by EEG 
technologist, minimum of 8 channels (95700) and video electroencephalogram (VEEG), review of data, 
technical description by EEG technologist, with continuous, real-time monitoring and maintenance, each 
increment of 12-26 hours (95716)
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. The Plan denied your request. The Plan says the enrollee does not 
meet all the required criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 document does not support necessity for admission to an IRF and the complexity of the enrollee's nursing, and medical needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative 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.