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

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic. 
 
You asked the Plan to pre-approve myocardial perfusion imaging, tomographic. You say that myocardial 
perfusion imaging, tomographic is medically necessary given the member's history and symptoms. The Plan 
denied your request. The Plan says myocardial perfusion imaging, tomographic does not meet the Medicare 
coverage criteria.  
 
The Plan follows Medicare rules.  
 
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 myocardial perfusion imaging, 
tomographic. Our reviewer says that myocardial perfusion imaging, tomographic is not medically necessary. 
Our physician reviewer found that the enrollee has had a history of atypical chest pains, with normal cardiac 
catheterization in 2016 and negative radionuclide stress tests in 2016 and 2019. The enrollees pre-test 
probability for an abnormal test is low and there is no documentation that the ECG shows an uninterpretable 
pattern. There is no evidence provided that would support the need for radionuclide stress testing. In summary, 
there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in 
this patients clinical 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 myocardial perfusion imaging, tomographic have not been met. Therefore, we 
decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care with the out-of-network provider. 
 
You asked the Plan to pre-approve continued care with the out-of-network provider. You say that the requested 
continued care with the out-of-network provider is medically necessary. The Plan denied your request. The 
Plan says the enrollee can transition to an in-network provider for manual therapy. 
 
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 continued care with the out-of-network 
provider. Our reviewer says that the requested continued care with the out-of-network provider is not medically 
necessary. Our physician reviewer found the enrollee is with a medical history of dystonia. A physical therapy 
progress note dated September 28, 2022, indicated that the enrollee was originally evaluated on April 24, 2017. 
Her last evaluation was performed on February 10, 2022. Treatment diagnoses included dystonia and muscle 
weakness. The enrollee has been receiving on-going physical therapy, including manual therapy and 
neuromuscular re-education, for her dystonia. She reports of muscle spasms that interfere with her daily 
activities and mobility. The enrollee was noted to have minimal loss of range of motion at the cervical and 
lumbar spine. She was noted to have hypomobility in the cervical spine with muscle hypertonicity. Physical 
therapy was recommended 1x every 2 weeks for 8 weeks. 
 
The enrollee has a medical history of dystonia and has been receiving ongoing physical therapy for treatment of 
her muscle spasms. This has included manual therapy, neuromuscular re-education, and motor planning 
training. This is treatment that can be provided by another physical therapist that is in-network for the 
enrollees insurance plan. Per the clinical documentation provided, there does not appear to be unique clinical 
circumstances that would require the enrollee to continue receiving treatment at the out-of-network provider. 
The enrollee should be able to be safely transition to another physical therapist that is in-network given the 
clinical documentation and diagnosis of dystonia. Therefore, the continued out-of-network physical therapy 
cannot be considered 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 continued care with the out-of-network provider have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continued care with the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve the requested services. You say that there are fewer and less serious long 
term side effects with proton therapy. The Plan denied your request. The Plan says the comparative efficacy 
evidence is still being developed. 
 
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 requested services. Our physician 
reviewer found that there is insufficient prospective, long-term clinical data available to determine whether or 
not proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam 
radiation therapy, IMRT, or brachytherapy with regards to safety and efficacy. The most recent guidelines state 
that PBRT offers no clinical advantage over other forms of definitive treatment. Therefore, proton beam 
radiation therapy is not medically reasonable and necessary 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup Lithium-ion battery for a Continuous positive 
airway pressure (CPAP) machine. 
 
You asked the Plan to pre-approve a backup Lithium-ion battery. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says a backup Lithium-ion battery for your 
CPAP machine is not covered by Medicare or the Plan. 
 
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 backup Lithium-ion battery for a Continuous positive 
airway pressure (CPAP) machine.
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 would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for admission to IRF. However, once you have completed your full hospital course, a new 
authorization with new documentation that supports the requested level of care, can be resubmitted. 
 
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 are no complex nursing or rehabilitation needs. While you have a need for 
physical 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: 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 the enrollee had a bilateral knee replacement. The 
Plan denied your request. The Plan says according to the available records, the enrollee does not meet all the 
required Medicare 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 the evaluating therapists recommend intense therapy but documentation does not 
show active comorbidities or hospital complications that would require continued inpatient hospitalization 
during rehabilitation. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for this enrollee. The 
Plan denied your request. The Plan says the criteria for admission to an IRF are not met in this case. The 
enrollee can safely receive the necessary services in 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 clinical documentation shows that the enrollee has functional impairments but there is no documentation of active comorbidities or hospital complications that would support continued 
inpatient hospitalization during rehabilitation. The listed functional impairments are not shown to be complex 
enough to warrant a multidisciplinary approach to rehabilitation. The criteria for an IRF are not met 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 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 you live alone and needs assistance with everything. 
You say you need extra time to regain your strength and control your pain. The Plan denied your request. The 
Plan says the IRF care is not medically necessary, and your needs can be met at a lower level of care such as a 
skilled nursing facility (SNF). 
 
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 are medically stable and does not need a physician's close supervision three 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no acute nursing needs identified or documented. You do not need three hours a 
day, five days a week of therapies with multidisciplinary approach 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that the ventilator is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer 
says that the portable ventilator is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee was successfully treated with BiPAP but was receiving BiPAP inconsistently at a skilled 
nursing facility. The enrollee's needs can be met with a BiPAP machine. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high utilization of non-preferred brand test strips. 
 
You asked the Plan to pre-approve a high utilization of non-preferred brand test strips. You say that the 
requested high utilization of non-preferred brand test strips is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for high utilization of non-preferred brand test strips. 
 
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 high utilization of non-preferred 
brand test strips. Our reviewer says that the enrollee does not meet criteria for high utilization of non-preferred 
brand test strips. Our physician reviewer found the record indicates that the enrollee has diabetes. The record 
provided is insufficient to establish the need for the specific quantity of supplies that exceeds the enumerated 
utilization amount described in the coverage criteria. The elements of the coverage criteria are not satisfied. 
The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a high utilization of non-preferred brand test strips have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a high utilization of non-preferred brand test 
strips.
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 you need skilled therapy to build up your strength 
and return home by yourself. The Plan denied your request. The Plan says you do not meet the criteria for 
admission to an SNF as the records do not show that you require daily skilled therapy services. It is feasible to 
meet your needs in a lower level of care. 
 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 that from a nursing perspective, you receive oral medications, have stable vital signs 
and tolerate an oral diet. Regarding rehabilitation services, you have received physical and occupational 
therapy services. You are at a stand-by assist/supervision level with functional mobility and require varying 
assistance with activities of daily living. You do not have identifiable skilled nursing service needs which 
would require the specialized skill, knowledge and judgement of a skilled professional nurse to safely and 
effectively provide medically necessary and reasonable treatment. Although you do have identifiable skilled 
therapy service needs, the documentation does not support that you require skilled therapy on a daily basis. As 
a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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: 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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for encephalopathy, septic shock, anemia, and renal failure. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT). 
 
You asked the Plan to pre-approve myocardial perfusion imaging, tomographic (SPECT). You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing without cardiac imaging will be 
considered medically reasonable and necessary when specific criteria are met. 
 
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 myocardial perfusion imaging, 
tomographic (SPECT). Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the enrollee has no cardiac symptoms. A stress test in 2019 was negative for ischemia. The enrollees 
pre-test probability for an abnormal test is low and there is no documentation that the electrocardiogram (ECG) 
shows an uninterpretable pattern. There is no evidence provided that would support the need for radionuclide 
stress testing. In summary, there is insufficient documentation to support the medical necessity for the 
requested cardiac stress testing in this enrollees clinical 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 myocardial perfusion imaging, tomographic (SPECT) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic 
(SPECT).