Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is still trach dependent and 
is too medically complex for a lower level of care. The enrollee also has endured a complex hospitalization and 
needs continued acute care to prevent further complications. The Plan denied your request. The Plan says based 
on Medicare guidelines the long term acute care hospital services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present setting. The enrollee does not require services 
at the LTACH that are not available at the acute care hospital where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-one. 
 
You asked the Plan to pre-approve Gel-one. 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 the patient's medical record should contain 
documentation that fully supports the medical necessity for intra-articular injections of sodium hyaluronate 
(Hyalgan, Supartz or Visco-3TM, EuflexxaTM, MonoviscTM, GelSyn-3TM, GenVisc 850, Durolane, 
TriViscTM, SynojoyntTM, TriluronTM), hylan G-F 20 (Synvisc, Synvisc-One TM), hyaluronic acid (Gel-One), 
high molecular weight hyaluronan (Orthovisc) and high molecular weight viscoelastic hyaluronan 
(Hymovis). 
 
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 Gel-one. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found this is an off-label use of this medication. 
The literature supporting it is use here is basically case series. It is considered experimental/investigational and 
therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the requested left heart 
catheterization is medically necessary. The Plan denied your request. The Plan says the requested left heart 
catheterization 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 left heart catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the medical necessity for performance of cardiac catheterization in this 
enrollee with no cardiac symptoms and coronary computed tomography (CT) imaging consistent with a 
possible narrowing in the mid-circumflex artery, for which revascularization would not be indicated.  
Guidelines do not support a need for this invasive study in this setting. As a result, at this time cardiac 
catheterization would not be considered medically appropriate and necessary in this enrollee's 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 left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a transforaminal epidural steroid injection. 
 
You asked the Plan to pre-approve a transforaminal epidural steroid injection. You say that a transforaminal 
epidural steroid injection is medically necessary. The Plan denied your request. The Plan says that under 
Medicare guidelines, your request is not medically necessary because the enrollee's exam is not consistent with 
radiculopathy and an objective pain scale was not utilized to document pain. 
 
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 a transforaminal epidural steroid 
injection. Our reviewer says that the requested transforaminal epidural steroid injection is medically necessary. 
Our physician reviewer found this 81-year-old enrollee has chronic low back pain. The enrollee takes Tramadol 
and Voltaren Gel for pain. She is status post an L4-L5 fusion. The MRI shows multi-level degenerative disc 
disease and spinal stenosis. The enrollees medical history is complicated by her morbid obesity. The enrollee 
had right L3, L4 and L5 transforaminal epidural steroid injections, which gave her greater than 50% pain relief 
for more than 3 months. The request meets the LCD criteria and is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transforaminal epidural steroid injection have been met. Therefore, we 
decided that the Plan has to pre-approve a transforaminal epidural steroid injection.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric hospital services 
beginning December 20, 2022. 
 
You asked the Plan to pre-approve continuation of inpatient psychiatric hospital services. You say that 
continuation of inpatient psychiatric hospital services is medically necessary. The Plan denied your request. 
The Plan says continuation of inpatient psychiatric hospital services is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 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 continuation of inpatient psychiatric 
hospital services. Our reviewer says that continuation of inpatient psychiatric hospital services is not medically 
necessary. Our physician reviewer found that based upon review the records provided, this enrollee does not 
meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of 
December 20, 2022 forward and could have been treated in a lesser restrictive setting as he was not showing 
any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any 
behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of inpatient psychiatric hospital services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient psychiatric hospital 
services beginning December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wearable mobile cardiovascular telemetry with 
electrocardiographic recording (code 93229). 
 
You asked the Plan to pre-approve a wearable mobile cardiovascular telemetry with electrocardiographic 
recording. You say that a wearable mobile cardiovascular telemetry with electrocardiographic recording is 
medically necessary. The Plan denied your request. The Plan says the requested wearable mobile 
cardiovascular telemetry with electrocardiographic recording does not meet the Medicare NCD 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 a wearable mobile cardiovascular 
telemetry with electrocardiographic recording. Our reviewer says that the requested wearable mobile 
cardiovascular telemetry with electrocardiographic recording is not medically necessary. Our physician 
reviewer found that the enrollee has a history of documented paroxysmal atrial fibrillation, but if ambulatory 
monitoring is felt to be needed, standard ambulatory ECG monitoring should suffice, according to the 
submitted records. As such, guidelines would not support a need for MCOT monitoring in this setting. In 
summary, there was insufficient documentation to support the medical necessity for an MCOT monitor 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 a wearable mobile cardiovascular telemetry with electrocardiographic recording 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a wearable mobile 
cardiovascular telemetry with electrocardiographic recording (code 93229).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 21, 2021, to December 24, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says there was no new documentation or clinical 
evidence presented to support an overturn of the initial audit findings. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 683. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, the documentation does not consistently and completely support the assigned diagnosis code 
with DRG. The replacement of DRG is upheld as it is supported by the medical documentation. The 
documentation does not indicate that the diagnostic work-up and treatment ordered by the treating medical 
providers supported a diagnosis code E87.2 (acidosis).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from December 21, 2021, to December 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve Mounjaro. You say that the requested drug is medically necessary for the 
enrollee. 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 Mounjaro.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transportation provided on May 27, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the air ambulance transportation. You say that the enrollee required interfacility 
transfers for treatment of his knee condition. The Plan denied your request. The Plan says this was not an 
emergency transport, and prior authorization was not requested for use of an OON provider. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. Approval was not requested for 
the OON service, and the Plan did not pre-approve the item/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the air ambulance transportation provided on May 27, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no evidence that the enrollee requires services that are not currently 
available at their current acute setting. The enrollee can remain at the current acute care hospital until no acute 
services are required. The enrollee can then be discharged to a lower level of care for any ongoing long term 
care needs. 
 
  
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a psychiatric hospitalization admission. 
 
You asked the Plan to pre-approve a psychiatric hospitalization admission. You say that this admission is 
medically necessary. The Plan denied your request. The Plan says the requested services have been correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric hospitalization admission. Our reviewer says that the medical criteria for a psychiatric admission have not been met. Our physician 
reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in 
question as she was not a danger to herself or others and does not have auditory or visual hallucinations. 
 
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 psychiatric hospitalization admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a psychiatric hospitalization admission.
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 healthy and need the special attention with 
inpatient rehab to regain maximum function. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that the enrollee has type 2 diabetes with diabetic 
polyneuropathy and without long-term current use of insulin. The Plan denied your request. The Plan says this 
Medicare Advantage plan does not cover outpatient prescription drugs. 
 
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 Ozempic.  
 
Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires another 4-6 weeks 
of close monitoring of his gastrointestinal, cardiac, respiratory, nutritional status and all intravenous 
medications can be continued as needed. The Plan denied your request. The Plan says based on Medicare 
guidelines the long term acute care hospital services you are requesting do not meet the requirements for 
approval. 
 
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 record indicates that the enrollee has a complicated hospital course and continues 
to have ongoing acute medical issues, requiring acute care services. The enrollee continues to receive acute 
care services. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. 
 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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device. 
 
You asked the Plan to pre-approve a MyoPro orthotic device. 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 a MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device.