Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair with a seat lift mechanism. 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that the enrollee would benefit from being 
able to stand from the chair more easily to prevent pressure sores. The Plan denied your request. The Plan says 
the criteria for this device have not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 the seat lift mechanism. Our reviewer 
says that the documentation does not support that the criteria for the seat lift mechanism are met. Our physician 
reviewer found the record does support that the enrollee has severe arthritis of the knee and hip. However, the 
records do not show that the patient is completely incapable of standing from a chair in the home. As such, the 
use of this device is not 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 the seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a chair with a seat lift mechanism.
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 documented skilled nursing 
needs or documented skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a 
practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. While the 
enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing facility or in-home with services. 
 
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 the radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve the RFA of the SI joint. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says this service is 
considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the RFA of the SI joint. Our reviewer 
says that radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, not medically necessary. Our physician reviewer 
found sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of 
sacroiliac joint mediated pain is considered experimental and investigational. 
 
 
 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 RFA of the SI joint have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abdominal lipectomy (excess skin removal). 
 
You asked the Plan to pre-approve the abdominal procedure. You say that you require this surgery due to skin 
issues and also to help with your ability to walk normally. The Plan denied your request. The Plan says as your 
weight has not been stable for 6 months, this cannot be approved at this time. 
 
The Plan follows Medicare rules. Medicare rules say that abdominal skin removal surgery is reasonable and 
necessary for enrollees with a stable weight for at least 6 months.  
 
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 abdominal procedure. Our reviewer 
says that the requested surgery is not considered medically reasonable and necessary at this time. Our physician 
reviewer found the record indicates that the enrollee has had massive weight loss after bariatric surgery. The record indicates that the enrollee's weight is not stable as the enrollee has gained over 16 pounds in the past 
several months. The elements of the coverage criteria are not satisfied.  
 
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 abdominal procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve abdominal lipectomy (excess skin removal).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Actemra intravenous solution. 
 
You asked the Plan to pre-approve Actemra intravenous solution. You say that Actemra is medically necessary 
for this patient's medical condition. The Plan denied your request. The Plan says that Actemra intravenous 
solution for a diagnosis of giant cell arteritis (inflammation of the lining of your arteries) is not a Food and 
Drug Administration (FDA) approved or compendia supported reason. 
 
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 Actemra intravenous solution. Our 
reviewer says that Actemra intravenous solution is medically reasonable and necessary for the enrollee. Our 
physician reviewer found the Food and Drug Administration has stated that the requested drug is indicated for 
the enrollee's condition. Our reviewer found that the elements of the coverage criteria are satisfied. The 
requested service 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 Actemra intravenous solution have been met. Therefore, we decided that the 
Plan has to pre-approve Actemra intravenous solution.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI breast bilateral with/without contrast. 
 
You asked the Plan to pre-approve an MRI breast bilateral with/without contrast. The Plan denied your request. 
The Plan says the requested MRI does not meet the Medicare NCD coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI breast bilateral with/without 
contrast. Our reviewer says that an MRI breast bilateral with/without contrast is not medically necessary. Our 
physician reviewer found the enrollee has a known ruptured silicone implant. There is no contraindication of 
screening mammography and no other criteria for MRI such as genetic predisposition etc. 
 
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 MRI breast bilateral with/without contrast have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an MRI breast bilateral with/without contrast.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Intracept procedure. 
 
You asked the Plan to pre-approve a Intracept procedure. 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health services from February 11, 
2022 forward. 
 
You asked the Plan to pre-approve the inpatient behavioral health services. You say that the services are 
necessary. The Plan denied your request. The Plan says the services are 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 the inpatient behavioral health services. Our reviewer says that the requested inpatient behavioral health services are not medically necessary. Our 
physician reviewer found the provided documentation indicates that the enrollee was not showing any 
dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not 
showing any acute threats of safety. It did not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question 
as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. 
Therefore, the reviewer found that the inpatient behavioral health services are not 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 the inpatient behavioral health services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient behavioral health services from February 11, 2022 
forward.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing visits in your home, and home health 
aide services. 
 
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 requested home health services are not medically necessary. 
 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 home health services are not medically necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled nursing services or skilled rehab 
services to provide treatment that is medically necessary. The enrollee does not require additional skilled 
nursing or rehabilitation services to effectively provide treatment, care, and/or services in order to improve the 
enrollees condition, perform a maintenance program to maintain the enrollees condition and/or prevent 
deterioration. The reviewer found that the enrollee has been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations.  The requested home health services are not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing visits in your home, and home health aide services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer. 
 
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration 
because the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is 
considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex Superion Spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex device is experimental, and more research is needed to show 
its 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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device. 
 
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration 
because the requested procedure is medically necessary. The Plan denied your request. The Plan says this 
procedure is considered experimental. 
 
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 Vertiflex Superion Spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record does not indicate that the enrollee has tried and six months of 
non-operative treatment and indicates favorable response to injections.  The record indicates that the enrollee is 
being treated for osteoporosis. 
 
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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that you would like reconsideration because the 
requested PET is medically necessary. The Plan denied your request. The Plan says that PET is not supported 
for the first staging of prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 the PET scan. Our reviewer says that a 
PET Scan is medically necessary and reasonable for the enrollee at this time. Our physician reviewer found a 
PET scan is needed to determine whether the enrollee has metastatic or localized cancer which would alter the 
treatment plan. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve the positron emission tomography (PET) scan.  
 
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 a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that your current wheelchair is too large. The 
Plan denied your request. The Plan says this cannot be covered within 5 years of your previous chair. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement during an items 5-year useful 
lifetime is limited to situations involving loss or irreparable damage from a specific accident or natural disaster 
(e.g., fire, flood, etc.).  
 
We looked at the file and Medicare rules. The record shows that you received your current wheelchair in 
October 2021, less than five years ago, and there is no documentation of loss or damage. Based on this 
information, we decided that Medicare rules for coverage of a power wheelchair have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says this does not serve a primarily medical purpose. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT of the abdomen and pelvis with contrast. 
 
You asked the Plan to pre-approve a CT of the abdomen and pelvis with contrast. You say that a CT of the 
abdomen and pelvis with contrast is medically necessary. The Plan denied your request. The Plan says that 
requested CT scan does not meet the Medicare NCD coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT of the abdomen and pelvis with 
contrast. Our reviewer says that a CT of the abdomen and pelvis with contrast is medically necessary. Our 
physician reviewer found that while no metastases have been shown before the last CT of the chest showed a 
probable adrenal adenoma. Lung cancer can sometimes metastasize to adrenals. Also, the enrollee has a fatty 
liver and borderline liver function tests. Surveillance CT of the abdomen and pelvis is reasonable in a patient 
with increased risk of metastatic disease. 
 
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 CT of the abdomen and pelvis with contrast have been met. Therefore, we 
decided that the Plan has to pre-approve a CT of the abdomen and pelvis with contrast.  
 
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.