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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 the enrollee appears to be improving with current treatment but is still somewhat 
unstable and requires additional acute care hospital services that can safely be provided at the current facility 
until more stable and appropriate for transfer. The enrollee does not require LTACH services that are not 
already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic leg with an electronic knee and advanced 
foot/ankle feature (Rheo microprocessor knee and Kinterra foot). 
 
You asked the Plan to pre-approve prosthetic leg with an electronic knee and advanced foot/ankle feature. You 
say that you disagree with the Plans denial. The Plan denied your request. The Plan says the requested items are 
not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that prostheses and accessories are only covered for 
certain indications. 
 
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 prosthetic leg with an electronic knee 
and advanced foot/ankle feature. Our reviewer says that the documentation does not support that the requested 
items are medically reasonable or necessary. Our physician reviewer found the enrollee had a right above-knee 
amputation on August 3, 2023. The enrollees previous ambulatory status, functional level, everyday activities 
and environment, and hobbies are not documented to justify K3 functional level. Therefore, the enrollee does 
not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetic leg with an electronic knee and advanced foot/ankle feature have not 
been met. Therefore, we decided that the Plan does not have to pre-approve prosthetic leg with an electronic 
knee and advanced foot/ankle feature (Rheo microprocessor knee and Kinterra foot).
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 states he needs that level of care. The 
Plan denied your request. The Plan says that admission to an IRF is not medically necessary and does not meet 
the criteria for coverage.  
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall.  There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 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 enrollee meets Medicare criteria and will benefit 
from acute inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare guidelines for services in an IRF.  
 
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 is non-weight bearing to the left hand and forearm. The enrollee's 
tracheostomy is decannulated and they are at goal with their tube feeds. The enrollee's medical issues are stable 
and they do not require thrice weekly visits with a rehabilitation physician.  
 
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says 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 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 
was admitted for hematuria. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that this 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pay for an SNF admission. You say that the enrollee is not in hospice care. You also say 
that the enrollee needs physical and occupational therapy and recommended skilled nursing to improve their 
mobility. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 an admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) (77014x6). 
 
You asked the Plan to pre-approve IGRT. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no good evidence for using IGRT for the enrollee's condition. Medicare does not 
cover unproven and not medically necessary procedures. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to help localize 
the target so as to minimize normal tissue dosing. Specifically, IGRT allows accuracy of treatment delivery, so 
when generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume 
of normal tissues exposed to radiation. For radiation in the palliative setting (as treating rheumatologic 
conditions with very low dose), the use of IGRT is generally considered not medically necessary outside of a 
medically plausible rationale. IGRT is simply being used as routine practice, as there does not seem to be any 
exceptional circumstances with this enrollee necessitating the need for IGRT. While the Halcyon machine has 
IGRT incorporated into all of its treatments, presumably it is not billed if not needed. The decision is 
unfavorable as IGRT is not an accepted standard of care for routine use in the palliative treatment of 
rheumatologic conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT) (77014x6).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pertuzumab injections (J9306) and administration (96413, 
96417) provided on August 16, 2021. 
 
You asked the Plan to pay for pertuzumab injections and administration. You say that these services were 
appropriate and medically necessary. The Plan denied your request. The Plan says this did not meet criteria for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for pertuzumab injections and administration. 
Our reviewer says that this use of pertuzumab is not supported. Our physician reviewer found the record shows 
that no prior chemotherapy was given and no chemotherapy was planned after this treatment. This is not a 
standard regimen. Pertuzumab should be given after other treatment or with carboplatin. This regimen is also 
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pertuzumab injections and administration have not been met. Therefore, we 
decided that the Plan does not have to pay for pertuzumab injections (J9306) and administration (96413, 
96417) provided on August 16, 2021.
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 enrollee would benefit from an inpatient acute rehab 
and will help avert unplanned readmission to the acute care hospital and ensure a safe discharge home where 
she can continue her recovery with home health and transition to a neuro outpatient program. The Plan denied 
your request. The Plan says that admission to an IRF is not medically necessary and does not meet the criteria 
for coverage.  
 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for COVID 19 infection, respiratory failure and congestive heart failure. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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: 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 the PET scan. You say that the enrollee has worsening memory, onset of 
enological symptoms, difficulty speaking and hatch sensory loss in face and hands. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
memory loss and signs or symptoms of frontotemporal dementia in the setting of a complex movement disorder 
without evidence or consideration of Alzheimer's disease. The record provided does not establish that the 
enrollee meets the diagnostic criteria of both Alzheimer's disease and frontotemporal dementia or that the 
examination is being requested in the context of a clinical trial. The elements of the coverage criteria are not 
satisfied. The requested service is not 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 the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs the ventilator and 
supporting information was submitted. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of a ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee had a COPD 
exacerbation likely from Influenza A infection resulting in acute on chronic hypercapnic and hypoxemic 
respiratory failure. The enrollee improved with appropriate therapy, including BIPAP therapy. The enrollee did 
not seem to require escalation of therapy nor fail BIPAP. Hence, no indication, per documentation and data 
provided for home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) office visits with a urologist to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you disagree with the denial and request 
reconsideration due to the enrollee spending half the year in Florida. The Plan denied your request. The Plan 
says the enrollee must use network providers to get medical care and services. The Plan also says out of state 
services are only covered for urgent/emergent care. 
 
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 Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 six (6) office visits with a urologist to be 
provided by an out-of-network (OON) provider.
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 require IRF services because you have a rare 
form of pneumonia and your breathing has not improved. The Plan denied your request. The Plan says your 
medical condition is stable and you do not meet the requirements for an 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 
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. You were admitted for 
anemia and gastrointestinal bleeding. Your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. Medically necessary services can be provided in 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dentures. You say that you want to have this covered as soon as possible 
due to your health. You say you need to have them fixed so you can bite and chew your food for living. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the maxillary partial denture was exhausted on date of service January 20, 2022 and 
your benefit for the mandibular partial denture was exhausted on date of service July 7, 2021. Therefore, we 
decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial 
denture (D5214).