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

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows that the enrollee has active comorbidities and would be expected to 
continue to require close medical supervision on an inpatient basis. It is recommended intense therapy and 
patient requires both physical therapy and occupational therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0862) and accessories 
(K0108, E1007, E2300, E2311, E2331, and E1012). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested 
group 3 power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested group 3 power wheelchair (K0862) and accessories 
(K0108, E1007, E2300, E2311, E2331, and E1012). 
 
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 group 3 power wheelchair and 
accessories. Our reviewer says that the enrollee does not meet criteria for the requested group 3 power 
wheelchair (K0862) and accessories (K0108, E1007, E2300, E2311, E2331, and E1012). Our physician 
reviewer found the enrollee has a mobility deficit that impairs mobility related activities of daily living 
(MRADLs) in the home. The enrollee's mobility limitation is not due to a neurological condition, myopathy, or 
congenital skeletal deformity. The documentation notes prior to amputations the enrollee was ambulatory. The 
April 29, 2022, therapy note indicates a manual wheelchair was used in therapy. The treating medical provider 
documentation does not support that the enrollee is unable to overcome his mobility deficit with a manual 
wheelchair. The October 3, 2022, therapy note indicates the enrollee is learning how to function with his 
prosthetic with a walker. There is also no detailed upper extremity neuromuscular/musculoskeletal exam 
indicating why an appropriate manual wheelchair cannot be used. 
 
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 group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0862) and accessories 
(K0108, E1007, E2300, E2311, E2331, and E1012).
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 is a high risk for falls, injury, and for re-
admission to acute care. The Plan denied your request. The Plan says based on Medicare guidelines, the 
inpatient rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found the enrollee's medical conditions appear stable on outpatient medications with no 
issues that appear to require a physician's evaluation three or more times per week. The provided records do not 
document any acute or unstable medical conditions or changes in medication or treatment which would 
necessitate hospital level care. The enrollee has been educated on the disease process and medications and has 
been discharged from home health nursing. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for this PET scan. 
 
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 PET scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found the 
enrollee has metastatic prostate cancer and a PET scan will not change treatment or outcome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical epidural steroid injection (ESI) (62321). 
 
You asked the Plan to pre-approve the ESI. You say that the enrollee has previously had medial branch blocks 
(MBBs) on July 19, 2022, with no relief. You say that the enrollee has tried conservative therapy with only 
short-term relief. You also say that the imaging from February 2022 indicate levoscoliosis of cervical spine, multilevel disc space narrowing, and retrolistheisis. The Plan denied your request. The Plan says the requested 
injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when radiculopathy, radicular pain and/or neurogenic claudication is 
severe enough to greatly impact quality of life or function. 
 
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 ESI. Our reviewer says that the 
requested ESI is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate any radicular symptoms, neurogenic claudication, post-laminectomy syndrome, and acute herpes 
zoster-related pain. Therefore, the reviewer found that the requested ESI is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve cervical epidural steroid injection (ESI) (62321).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of an auricular electro-acupuncture device. 
 
You asked the Plan to pre-approve electro-acupuncture device. You say that you are likely to obtain significant 
therapeutic benefit from this device. The Plan denied your request. The Plan says this device is not covered by 
Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.    
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve use of an 
auricular electro-acupuncture device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octagam. 
 
You asked the Plan to pre-approve Octagam. The Plan denied your request. The Plan says this drug is not being 
supplied by the physician and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Octagam.  
 
 
 
 
 
 
 
 
 Benefits for Octagam 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging for the enrollee.  
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show any chest pain/angina, or new onset heart failure. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there are no cardiac symptoms since percutaneous coronary intervention in 2021. 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 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on December 8, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says traditional Medicare is the primary payer when in hospice care. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the documentation does not support that the services 
are being requested for chronic low back pain. Therefore, we decided that the Plan does not have to pre-
approve acupuncture 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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition you do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical status does not require intensive physician and nursing oversight in an 
IRF.  While you may benefit from additional multiple therapies, including physical and occupational therapy, the 
documentation does not reveal that you require this therapy on an intensive IRF level. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a psychologist (99203) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you need mental health services and have been 
looking for a mental health provider for five months. The Plan denied your request. The Plan says you must 
receive your care from a network provider. The medical care you require can be provided by a network 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with a psychologist (99203) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (CMT) (98940) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the CMT. You say that the enrollee's medical doctor does not do referrals, 
but sent a radiology report that shows indication that chiropractic treatment would help the enrollee's condition. 
The Plan denied your request. The Plan says the requested treating provider is not in the Plan's network. The 
Plan also says there is no medical need shown as to why the enrollee cannot get this care from an in-network 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic manipulative treatment (CMT) (98940) to be provided by an out-of-network (OON) provider.
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 this is medically necessary. The Plan denied your 
request. The Plan says according to the clinical information submitted with the request, the enrollee does not 
meet the Centers for Medicare and Medicaid Services (CMS) 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not qualify for SNF coverage. You do not have documented skilled 
nursing needs.  You do not have documented skilled therapy needs. You are walking household distances and 
tending to ADLs with minimal supervision. Daily skilled services are not shown to be 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show any of the indicated diagnoses. 
 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested test was ordered by the provider to help diagnose/rule out an  underlying leukemia/ 
myelodysplastic syndrome (MDS), or myeloproliferative neoplasm (MPN). The enrolee does not meet the 
coverage criteria for the test. The review has determined that the enrollee does not need the targeted genomic 
sequence analysis panel. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a targeted genomic sequence analysis panel for the enrollee.