Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Image Guided Radiation Therapy (IGRT) (77387, G6002). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is a medical necessity due to enrollee movement 
on a daily basis. The Plan denied your request. The Plan says that daily IGRT is not considered medically 
necessary or needed or effective when delivering palliative humeral head 10 fraction radiotherapy, especially in 
a medically uncomplicated situation such as this. 
 
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 IGRT. Our reviewer says that the 
requested items/services are 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, IGRT could be considered 
medically necessary when it is necessary to escalate the dose (i.e., oligometastases), particularly when using 
very high dose per fraction, or when critical normal tissues abutting the target necessitate daily image guidance 
to allow minimal planning margins to spare the normal tissue. For the palliative treatment of bone metastases, 
the use of IGRT is generally considered not medically necessary outside of a medically plausible rationale (i.e. 
prior radiation treatment, unusual anatomy). In this case, while the intent is palliative, the radiation oncology 
referral to treatment described the need for IGRT due to large shifts and non-reproducible set-up. It is not clear 
why this was the case, though the records do demonstrate daily shifts that would demonstrate that IGRT was 
needed for this enrollee. The decision is favorable as IGRT is an accepted standard of care for exceptional 
cases when used for difficult set-up with the palliative treatment of bone metastases. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
Image Guided Radiation Therapy (IGRT) (77387, G6002).  
 
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 the life2000 (E0466). 
 
You asked the Plan to pre-approve the life2000. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 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 the life2000. Our reviewer says that the 
enrollee does not need this item. Our physician reviewer found the patient has not failed BIPAP or BIPAP with 
average volume-assured pressure support (AVAPS).  
 
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 life2000 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the life2000 (E0466).
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 the enrollee's current condition requires 
an LTACH admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient acute care and does not require transfer to an LTACH. 
 
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 the enrollee does not have needs that indicate an LTACH transfer is required. 
 
 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: 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 these services would benefit the enrollee to regain 
their maximum function. The Plan denied your request. The Plan says the required services can be provided in 
an alternate setting.  
 
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's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies. 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not need specialized training, staff, or equipment 
available only in an IRF. The Plan says that the services needed may be provided safely in a lower level of 
care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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.  
 
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: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on March 10, 2023, to April 27, 2023. 
 
You asked the Plan to waive the copayment for SNF. You say that you disagree with the copayment. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment per day for days 1-20 and a $184 copayment per day for days 21-100 for skilled nursing facility 
(SNF) care.  
 
 You have been asked to pay a $0 copayment per day for days 1-20 and a $184 copayment per day for days 21-
100 for SNF. The total allowed amount for the SNF is $2,944. ($184 x 16 days =$2,944). However, since the 
allowed amount is less than the standard copayment, you only owe $2,849.56. This item/service falls within the 
skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
skilled nursing facility (SNF) care provided on March 10, 2023, to April 27, 2023.
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 is able to sustain the three hour daily 
requirement of therapy required from acute rehabilitation. You say the enrollee will benefit greatly from acute 
rehabilitation to return to their prior level of function was was independent. The Plan denied your request. The 
Plan says the IRF services requested 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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 waive the cost share for inpatient hospital care, prosthetic devices 
and skilled nursing facility (SNF) provided on March 3, 2023, to April 25, 2023. 
 
You asked the Plan to waive the cost share for inpatient hospital care, prosthetic devices and SNF. You say that 
you disagree with the cost share. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for days 1-5 for inpatient hospital care, a 20% coinsurance for prosthetic devices and a $196 copayment for days 21-100 for skilled nursing facility (SNF).  
 
You have been asked to pay a $325 copayment per day for days 1-5 for inpatient hospital care, a 20% 
coinsurance for prosthetic devices and a $196 copayment for days 21-100 for SNF. The total amount you owe 
for inpatient care is $1,625 ($325 x 5 days = $1,625). The total allowed amount for the prosthetic is $284. You 
are being asked to pay $56.80 ($284 x 20% = $56.80). The total amount you owe for SNF is $784 ($196 x 4 
days = $784). The total amount you are being asked to pay is $2,465.80 ($1,625 + $56.80 +$784 =$2,465.80). 
This item/service falls within the inpatient hospital care, prosthetic devices and skilled nursing facility (SNF) 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost share for inpatient hospital care, prosthetic 
devices and skilled nursing facility (SNF) provided on March 3, 2023, to April 25, 2023.
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 is medically necessary. The Plan denied 
your request. The Plan says you have chronic medical conditions, these issues do not require the expertise of 
rehabilitation physician in an IRF. The Plan says that the services needed may be provided safely in a lower 
level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter implantation of wireless pulmonary 
artery pressure sensor for long-term hemodynamic monitoring (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the device is medically necessary. The 
Plan denied your request. The Plan says the CardioMEMS device has been determined to be of uncertain value 
and carries a risk of significant complications including death and severe pulmonary artery injury. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the Food and Drug Administration (FDA) 
in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary 
artery pressure in the management of enrollees with congestive heart failure (CHF). The clinical study on 
which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in enrollees 
in whom the CardioMEMS system was implanted, reflecting an enrollee population with preserved ejection 
fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an 
improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in enrollee management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollee's 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transcatheter implantation of wireless pulmonary artery pressure sensor for 
long-term hemodynamic monitoring (33289).
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 needs aggressive therapy. The Plan 
denied your request. The Plan says the enrollee will have difficulty participating in daily intensive therapy.  
 
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 was admitted to the acute care hospital for rib fractures and facial 
hematoma. Her medical problems are stable. The patient does not require treatment by multiple therapies in an 
intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
September 23, 2022, to September 26, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you have not had to pay 
for this service in the past. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment each day, for days 1 to 7 and a $0 $0 copayment each day, for additional Medicare-covered days 8 
to discharge each time you are admitted for in-network Medicare-covered hospital care. 
 You have been asked to pay a $325 copayment per day, for days 1 to 2 of the inpatient hospital stay. You have 
been asked to pay a total of $650 ($325 copayment x 2 days = $650). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an inpatient hospital stay provided from September 23, 2022, to 
September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve water vapor thermal therapy (53854). 
 
You asked the Plan to pre-approve water vapor thermal therapy. You say that you do not agree with this denial. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that one treatment for lower urinary tract symptoms 
attributable to benign prostatic hyperplasia (LUTS/BPH) treatment is covered once in patients with a maximum 
urinary flow rate (Qmax) of 15 mL/s, and a prostate volume of 30 to 80 cc. 
 
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 water vapor thermal therapy. Our 
reviewer says that the requested water vapor thermal therapy is not medically necessary. Our physician 
reviewer found the provided documentation does not indicate a maximum urinary flow rate (Qmax) of at least 
15 milliliters per second (mL/s) (voided volume greater than 125 cubic centimeters (cc). The documentation 
does not indicate a prostate volume of 30 to 80 cc. Therefore, the reviewer found that the request for water 
vapor thermal therapy 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 water vapor thermal therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve water vapor thermal therapy (53854).