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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair, multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and accessories (E0955, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2611, E2622, K0040). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you have spinal stenosis, 
which has caused nerve damage as well as paralysis in your legs. You are bed bound and you are unable to 
walk or stand. The Plan denied your request. The Plan says you do not have a medical diagnosis of 
neurological disease, myopathy or congenital skeletal deformity. Your current mobility deficit is a result of 
arthritis. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy, or 
congenital skeletal deformity. As you do not qualify for the requested wheelchair, none of the requested 
accessories can be covered. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 
pounds (K0861) and accessories (E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2611, E2622, 
K0040).
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 this should be approved as it is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not have complex rehabilitation needs and can 
receive the services they need at a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation supports that most inpatient skilled therapy goals have been met, and that the enrollee no longer has any specified complex functional impairments. As such, the complexity of 
the documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve bilateral lumbar radiofrequency ablations at the L1-L2 and L5-S1 
levels. 
 
You asked the Plan to pre-approve bilateral lumbar radiofrequency ablations at the L1-L2 and L5-S1 levels. 
You say that you are in a lot of pain and the need for the requested injection services is supported by the 
records provided. The Plan denied your request. The Plan says that the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 bilateral lumbar radiofrequency 
ablations at the L1-L2 and L5-S1 levels. Our reviewer says that bilateral lumbar radiofrequency ablations at the 
L1-L2 and L5-S1 levels are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of chronic lower back pain. The pain is aggravated with increased 
activity. The x-ray of the lumbar spine obtained on August 27, 2022, revealed L3-S1 anterior/posterior fusion 
changes with intervertebral grafts and bilateral pedicle screws at L3-S1. The enrollee has taken tramadol, 
ibuprofen, hydrocodone, Aleve, and gabapentin the past for her pain. The prior treatments include rest, home 
exercise, stretching, lifestyle modification, massage, and use of a transcutaneous electrical nerve stimulation 
(TENS) unit. A March 7, 2023, clinic record states that the enrollee has had radiofrequency denervation 
(ablation) in the past which helped some. On January 18, 2023, she underwent bilateral L1-L2 and L5-S1 
lumbar medial branch blocks with bupivacaine injected with 80% pain relief. On February 22, 2023, she 
underwent a repeat bilateral L1-L2 and L5-S1 lumbar medial branch blocks with bupivacaine injected with 
80% pain relief. The sites of the proposed injections do not involve the site of prior surgery. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral lumbar radiofrequency ablations at the L1-L2 and L5-S1 levels have 
been met. Therefore, we decided that the Plan has to pre-approve bilateral lumbar radiofrequency ablations at 
the L1-L2 and L5-S1 levels.  
 
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 MyoPro orthotic device. 
 
You asked the Plan to pre-approve the requested device. You say that the device is supported as an appropriate 
intervention. The Plan denied your request. The Plan says the device is unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested device. Our physician 
reviewer found that the enrollee has right upper extremity partial paralysis after suffering a stroke in 2019. The 
MyoPro orthosis is not known to be effective, based on scientific evidence, professional standards and expert 
opinion, in improving health outcomes. The MyoPro is not the standard of care for this enrollees condition or 
in widespread use for this enrollees condition based on scientific evidence. There is insufficient evidence in 
the literature that the MyoPro orthosis will improve the long-term outcomes for this enrollee. 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 the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-network cardiology services at an in-network 
benefit level. 
 
You asked the Plan to pre-approve an in-network benefit level. The Plan denied your request. The Plan says the 
enrollee may use the out-of-network benefit at a higher out of pocket cost. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that care can be received from a provider who is eligible to provide services under Original Medicare. 
 
The requested provider in this case is not a network provider with the Plan. However, the enrollee has out-of-
network benefits at a higher cost share. We found no exception that would require the Plan to pre-approve an 
in-network rate. Therefore, we decided that the Plan does not have to pre-approve out-of-network cardiology 
services at an in-network benefit level.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has a weakness on their right side and 
are unable to walk to enter their home. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary, and the enrollee's needs can be met in another setting. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 due to the enrollee's medical complexity, difficulty 
in managing without a full team and knowledgeable therapist, the enrollee will not make adequate strides. 
 The Plan denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs 
can be met at a lower level of care such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was diagnosed and treated for acute on chronic hypercarbia respiratory 
failure and an exacerbation of congestive heart failure and pneumonia. The enrollee has been treated medically 
and has stabilized and improved. There is not a reasonable expectation that this individual will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avsola. 
 
You asked the Plan to pre-approve Avsola. You say that you are having a flare up. The Plan denied your 
request. The Plan says you have not failed Remicade, infliximab or Inflectra, and Stelara. 
 
 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 Avsola. Our physician reviewer found 
that you have Crohn's disease. The requested medication is a new start. The Plan requires a trial of Remicade, 
infliximab or Inflectra, and Stelara before they will approve the requested drug. The provided records do not 
indicate that you have tried and failed the Plan's preferred step one alternative. The record does not indicate that 
you have a contraindication to or would have an adverse effect from the Plan's preferred step one alternative.  
The elements of the coverage criteria are not satisfied. The requested service cannot be 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 Avsola have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avsola.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage have not been 
met because the lifetime benefit for inpatient psychiatric care provided in a psychiatric hospital has been 
exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided documentation to support that the 
enrollee has received 190 days of inpatient psychiatric care at a psychiatric hospital. We therefore cannot 
corroborate that the lifetime has been exhausted. The Plan has not provided any alternative rationales for 
denial. It is the Plan's responsibility to substantiate its denial with evidence. In this case, the Plan's denial has 
not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pre-approve 
inpatient psychiatric care.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
members nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy 
program. The member continues to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that she would meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that the member would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain her functional status. The member can receive 
further services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system (E0637). 
 
You asked the Plan to pre-approve a combination sit to stand frame/table system. You say that the enrollee 
needs the device to regain some semblance of daily function and ambulation. The Plan denied your request. 
The Plan says this request is not medically necessary. The Plan also says that although the records show that 
the enrollee requires a patient lift to assist with transfers, there is no documentation to support why this code 
was used over a Medicare approved code which would justify payment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a combination sit to stand frame/table system (E0637).
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's needs to continue weaning 
from a ventilator. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee's needs can be met in the current hospital 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 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 the available records, 
the enrollee does not meet all the required criteria for admission to an Inpatient Rehabilitation Facility. Skilled 
therapies at home or at a skilled nursing facility may be approved upon request 
 
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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The 
enrollees care needs can be met 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 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.