Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits. 
 
You asked the Plan to pre-approve the requested services. You say that you are struggling to keep up with care. 
The Plan denied your request. The Plan says you have already been educated in a home exercise program. 
 
 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 the requested services. Our physician 
reviewer found that in this case, the documentation does not support that you require additional skilled rehab 
services to provide treatment that is medically necessary. You do not require additional skilled rehab services 
to effectively provide treatment to improve your condition or perform a maintenance program to maintain your 
condition or prevent deterioration. You have been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. Therefore, 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous passive motion exercise device for use 
on knee only (E0935). 
 
You asked the Plan to pre-approve the continuous passive motion device. You say that you would appreciate 
reconsideration for the continuous passive motion machine for your left knee recovery. The Plan denied your 
request. The Plan says the enrollee's knee surgery was 5 months ago and does not meet the criteria as coverage 
is limited to 3 weeks period following surgery. 
 
The Plan must follow Medicare rules. The rules say that coverage for CPM devices is limited to the three-week 
period following total knee replacement surgery during which the device is used in the home. 
 
Records show that the enrollee had a total knee arthroplasty on 10/13/2021 and manipulation under anesthesia 
on 12/2021. Coverage is limited to the 3-week period following surgery during which the device is used in the 
home. Therefore, we decided that the Plan does not have to pre-approve the continuous passive motion exercise 
device for use on knee only (E0935).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement durable medical equipment is 
covered in the case of irreparable damage or when the equipment as exceeded the reasonable lifetime period of 
five years. 
 
We looked at the file and Medicare rules. The file shows that the enrollee's current CPAP is not irreparably 
damaged or more than five years old. Therefore, we decided that the Plan does not have to pre-approve a 
replacement continuous positive airway pressure (CPAP) device.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Euflexxa. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug 
Orthovisc, Synvisc or Synvisc One before they will approve the requested drug. In this case, you have not tried 
and failed the required drug(s). There is no documentation provided indicating that the plans required drug(s) 
would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the service 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 Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. The enrollee is 81 years old. This procedure is only covered for enrollees ages 55 to 77. Therefore, we decided that the Plan does not have to pre-approve a low dose computed 
tomography (LDCT) scan for lung cancer screening.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF level of care. The Plan 
denied your request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's 
ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that it is not clear that the enrollee is stable for an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee 
in this case requires at least 3 hours a day, 5 days a week, or 15 hours over 7 consecutive days, of therapy 
services. It is not clear that the enrollee will be able to fully participate in, and benefit from, the intensive 
rehabilitation therapy program provided 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the home health services. You say that your home health physical therapy 
ran out, you did not use it much during the holidays, and would like to appeal for an extension. The Plan denied 
your request. The Plan says you do not meet Medicare's medical necessity criteria for coverage of home health 
services. 
 
  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 the home health services. Our reviewer 
says that ongoing home health services are not medically necessary or reasonable. Our physician reviewer 
found you do not have documented ongoing, skilled needs. Our reviewer found that your needs are highly 
custodial, and you are able to perform a home exercise program (HEP). Our physician reviewer also found that 
you live with family/caregivers. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept Procedure. 
 
You asked the Plan to pre-approve the Intracept Procedure. You say that you would like reconsideration 
because this 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 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 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 Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept Procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 Power wheelchair and accessories. 
 
You asked the Plan to pre-approve a Group 3 Power wheelchair and accessories. You say that a Group 3 Power 
wheelchair and accessories is medically necessary. The Plan denied your request. The Plan says Medicare 
criteria for a Group 3 Power wheelchair and accessories are not met. The Plan states that you do not have a 
need for both power tilt and power recline. Medicare coverage criteria are not met.  
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for Group 3 Power Wheelchairs.  
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity that requires a need for both power tilt and power recline. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 Power wheelchair and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires this higher level of care. The 
Plan denied your request. The Plan says IRF care is not medically reasonable and 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted on 3/14/2022 with abdominal pain.  The enrollee underwent emergent sigmoid colectomy on 3/16/22 for perforated sigmoid diverticulitis. As of 
3/22/2022, she was able to ambulate 5 feet, and only 20 with a walker. By 4/4/2022, her activity tolerance 
remained limited by fatigue and was able to tolerate approximately 5 minutes of standing activity before 
needing a seated rest break. 
 
The documentation does not support that the enrollee requires an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. While the enrollee would benefit from treatment by multiple 
therapies, including physical therapy and occupational therapy, the documentation does not support that the 
enrollee will be able to fully participate in, and benefit from, an intensive rehabilitation therapy 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablets. 
 
You asked the Plan to pre-approve Eliquis tablets. The Plan denied your request. The Plan says Eliquis is a 
self-administered drug and does not fall under Part B coverage. 
 
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 Eliquis tablets.  
 
Benefits for Eliquis tablets 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert system for the enrollee. 
 
You asked the Plan to pre-approve a Life Alert system. You say that a Life Alert system is medically necessary 
for the enrollees safety. The Plan denied your request. The Plan says this equipment and service are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not pay for precautionary equipment. This item is 
available to the 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 Life Alert system for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will greatly benefit from IRF care to 
increase independence, address and treat his wound, assess equipment needs, establish bowel and bladder 
program and to provide patient education, pain control and caregiver education. The Plan denied your request. 
The Plan says based on Medicare guidelines, the request for IRF services does 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 that the complexity of the enrollees nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While 
the documentation does support a need for physical and/or occupational therapy, there is no documented need 
for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided 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: 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 IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity rules for IRF care have not been met. 
 
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 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided 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: 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 would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the IRF 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 complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
documentation does not support that you require at least 3 hours a day /5 days a week, or 15 hours over 7 
consecutive days, of therapy 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108, 
E1028, E0956, E2617). 
 
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The 
Plan denied your request. The Plan says the accessories cannot be covered. 
 
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 additional accessories. Our reviewer 
says that the requested additional accessories are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that in this case, the documentation doesnt support that you have a need 
for an additional seat width, that there are significant postural asymmetries, indication for specialized hardware 
or a prefabricated cushion. The requested accessories 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 additional accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional power wheelchair accessories (K0108, E1028, E0956, E2617).