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

 
We decided that the Plan does not have to pre-approve the myoelectric prosthetic hand. 
 
You asked the Plan to pre-approve the myoelectric prosthetic hand. You say that you would like 
reconsideration because the enrollee has had a decline in dexterity. The Plan denied your request. The Plan says 
there is no documentation of which body powered prosthesis were considered, trialed or failed to meet the 
functional needs to perform activities of daily living. 
 
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 myoelectric prosthetic hand. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records do not document trial and failure of a body-powered prosthesis. 
 
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 myoelectric prosthetic hand have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the myoelectric prosthetic hand.
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 would benefit from intensive inpatient 
therapy and 24-hour rehabilitation nursing care. You say that the patient is at high risk for deep vein thrombosis 
and meets the full criteria for an inpatient rehabilitation stay under CMS guidelines. The Plan denied your 
request. The Plan says the member's medical and therapy needs could be met in a skilled nursing unit. 
  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 enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the occupational therapy (OT) (97168). 
 
You asked the Plan to pre-approve the OT. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 OT. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the additional requested therapy generally is not accepted as specific and 
effective therapy for the patients condition beyond what was approved by the plan. The patient has had prior 
therapy and the documentation does not reveal that the patient requires the unique skills of a professional 
therapist to safely and effectively provide treatment, or that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The patient lives in long term care 
and has assist for her ADLs. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
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 OT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the occupational therapy (OT) (97168).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary when specific criteria 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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no imaging study showing an acute 
fracture that is less than 6 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an echocardiogram. 
 
You asked the Plan to pre-approve an echocardiogram. You say that the service is medically necessary. The 
Plan denied your request. The Plan says he service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an echocardiogram. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Echocardiography is indicated if there are symptoms or physical findings suggestive of a 
significant cardiac abnormality, or another test abnormality suggestive of significant cardiac pathology such as 
an ECG or chest X ray. It is also indicated to assess the status of a known cardiac condition where the findings 
would be utilized to adjust medications, such as with a cardiomyopathy, for monitoring of known valvular 
disease, or assess the status of a known underlying cardiac condition when there exists symptomatic and / or 
physical finding changes. The enrollee had symptoms of dizziness and vertigo. 
 
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 echocardiogram have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an echocardiogram.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Clobetasol solution. 
 
You asked the Plan to pre-approve Clobetasol. You say that the enrollee has been using the requested drug for 
several months with good improvement. The Plan denied your request. The Plan says the requested drug is 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Clobetasol solution.  
 Benefits for Clobetasol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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. The 
enrollee's rehab can be safely provided at a lower intensity and alternate setting such as in a skilled nursing 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you have diabetes and require insulin. You feel that 
this device should be covered. The Plan denied your request. The Plan says you do not meet the criteria for the 
requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. The records show that you use one injection of a long-acting insulin per day. 
Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that the enrollee has tried previous medications that were 
ineffective or cause side effects. The Plan denied your request. The Plan says the enrollee has not tried and 
failed at least 2 of the required drugs, Humira, Rinvoq, Skyrizi, Actemra, Cosentyx, Otezla, Xeljanz or Xeljanz 
XR, Orencia, and Enbrel. 
 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 Ilumya. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternatives. The record does not indicate that the 
enrollee has a medical contraindication to, or would have an adverse effect from the plan's preferred step one 
alternatives. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
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 member does not have a support system at home. 
You say that the member needs inpatient rehab due to having two broken arms and needs to get muscle control. 
The Plan denied your request. The Plan says care can safely be received in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional PT visits. 
 
You asked the Plan to pre-approve PT visits. You say that additional PT is medically necessary. The Plan 
denied your request. The Plan says additional PT is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found that the additional requested therapy generally is not accepted as specific and 
effective therapy for your condition beyond what was approved by the Plan. You have had prior therapy and 
the documentation does not reveal that you require the unique skills of a professional therapist to safely and 
effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or 
by or under the supervision of a therapist. You can participate in an independent home exercise program in 
which you were instructed. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PT visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional PT visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need 24-hour nursing, a multi-disciplinary team 
and pain control. You say that you need a more structured rehab and a strategy plan before going back home. 
The Plan denied your request. The Plan says you can safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require treatment by multiple therapies and an intensive rehabilitation 
therapy program. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0800). 
 
You asked the Plan to pre-approve a power wheelchair (K0800). You say that the requested power wheelchair 
(K0800) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested power wheelchair (K0800). 
 
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 power wheelchair (K0800). Our 
reviewer says that the enrollee does not meet criteria for the requested power wheelchair (K0800). Our 
physician reviewer found the documentation does not support that the enrollee has a mobility deficit that 
impairs mobility related activities of daily living (MRADLs) in the home and this mobility limitation is not 
ameliorated by a walker or manual wheelchair. While the provider notes the enrollee has unstable gait and 
weakness the February 3, 2022, progress note indicates normal cognition, no gait or balance abnormality, and 
neuro exam grossly normal. While the enrollee may have the cognition to safely operate the K0800 the 
documentation does not reveal a home assessment to support that the requested device will be able to safely 
maneuver in the home and access rooms for MRADL participation. The documentation does not support that 
the K0800 will significantly improve the enrollees ability to participate in MRADLs and the enrollee will use 
it in the home. The documentation does not reveal that the requested K0800 mobility device is medically 
necessary per Local Coverage Determination (LCD): (L33789). 
 
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 power wheelchair (K0800) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power wheelchair (K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm (J0172). 
 
You asked the Plan to pre-approve Aduhelm. You say that common causes of cognitive impairment or 
dementia have been ruled out. The Plan denied your request. The Plan says the requested drug is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Aduhelm. Our reviewer says that the 
requested drug, Aduhelm, is not medically necessary. Our physician reviewer found the documentation 
supporting a diagnosis of Alzheimer's disease is limited and inconsistent. The reviewer found that the magnetic 
resonance imaging (MRI) in this case suggests a mixed etiology for the enrollee's symptoms. The reviewer also 
found that the provided documentation does not support that Aduhelm is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aduhelm (J0172).