Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this treatment is considered safe and 
effective and should be approved for the enrollee. The Plan denied your request. The Plan says there is 
dextroscoliosis and degenerative disease as well as multi-level disease to L2 to L3 involving facet joints, lateral 
recesses, and discs. The Plan says that given the diffuse disease, the medical necessity of treatment of only L2 
to L3 is not established. 
 
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 Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is considered experimental as additional research is needed. Therefore, the reviewer found that the Vertiflex device is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Vertiflex Superion interspinous device (22869).
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 services are medically necessary for your 
complex medical needs. The Plan denied your request. The Plan says you do not meet the criteria for admission 
to 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-spinal bone growth stimulator.  
 
You asked the Plan to pre-approve the requested BGS. You say that this BGS is needed as the enrollee has not 
had significant healing of a stress fracture of the acromion.  The Plan denied your request. The Plan says BGS 
is not covered for fractures of the bone at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that BGS may be covered for long bone fractures 
which have not healed for at least 90 days. 
 
 We looked at the file and Medicare rules. Though there is a non-healing fracture, it is of the acromion, part of 
the scapula, which is not considered a long bone per Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested BGS have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a non-spinal bone growth stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerve. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says this 
service is not standard medical treatment for the enrollee's condition.  
 
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 services. Our physician 
reviewer found that the enrollee has a history of chronic knee pain due to bilateral primary osteoarthritis of 
knee. Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically 
necessary for the treatment of chronic knee pain, including, osteoarthritis. The review has determined that the 
requested radiofrequency ablation of the right genicular nerve is not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (NIV). 
 
You asked the Plan to pre-approve the NIV. You say that the enrollee requires the ventilator requested. The 
Plan denied your request. The Plan says the enrollee has not failed treatment with BiPAP. 
 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 NIV. Our reviewer says that the 
NIV is not considered medically reasonable and necessary. Our physician reviewer found the enrollee has 
COPD and is using the NIV is average volume-assured pressure support (AVAPS) mode. The enrollee's needs 
could be met by a BiPAP device with back-up rate.  
 
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 NIV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a non-invasive ventilator (NIV).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says you do not meet the criteria for admission. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (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 the enrollee has a serious, life-threatening 
constellation of acute medical problems which leaves the enrollee functionally below baseline. The Plan denied 
your request. The Plan says 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 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 femur after a fall. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate Sodium tablets. You asked the Plan to pre-approve Methotrexate Sodium tablets. You say that this medication has shown 
promising results in slowing the progression of aortitis and retroperitoneal fibrosis. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for the requested medication. 
The Plan follows Medicare rules. Medicare rules say that a drug is covered if 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 Methotrexate Sodium tablets. Our 
reviewer says that the medication is not medically necessary. Our physician reviewer found that Methotrexate 
sodium tablets are not FDA-approved for aortitis and retroperitoneal fibrosis. Therefore, the requested use of 
Methotrexate sodium tablets cannot be approved at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Methotrexate Sodium tablets have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Methotrexate Sodium tablets.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says that the testing 
is not required for treatment of the enrollee's condition.  
 
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.  
 
The file shows that JAK2 testing has been requested. 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 genetic testing. Our physician reviewer found that the enrollee has polycythemia. The National 
Comprehensive Cancer Network (NCCN) guidelines do support the testing for the enrollee's condition. JAK2 
testing is medically necessary for those with polycythemia vera. Therefore, the request is medically 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 genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve genetic testing.  
 
 
 
 
 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says documentation does not support that the enrollee has a medical 
condition or comorbidities requiring a physician to monitor face to face, at least 3 days a week. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing visits and four occupational 
therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the enrollee had spine surgery and is 
bedridden. You also say that the enrollee has a care worker that does cooking, cleaning and bathing but she 
needs a physical therapist to strengthen her legs. The Plan denied your request. The Plan says the services are 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
documentation provided the enrollee does not have documented skilled nursing needs or skilled occupational 
therapy needs. As such, the requested home health skilled nursing and occupational therapy services are not 
medically 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional skilled nursing visits and four occupational therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the request is 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 the medication. Our reviewer says that 
the request is medically necessary. Our physician reviewer found that the record indicates the enrollee has a 
diagnosis of Crohns disease and is receiving oral iron supplementation. The Food and Drug Administration 
has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
 
  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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and one power 
seating system motor. You say that the enrollee has limitation of fine motor controls and dexterity in their 
hands which makes it difficult or impossible to differentiate the different switches that would individually 
control powered seating functions. The Plan denied your request. The Plan says the requested service is not 
covered by Medicare or the health plan. 
 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 electronic connection between 
wheelchair controller and one power seating system motor. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested 
E2310 exceeds the enrollee's functional need. Our physician reviewer also found that the enrollee's strength and 
functional ability allow them to control any power options through their own switches. 
 
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 electronic connection between wheelchair controller and one power seating 
system motor have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection between wheelchair controller and one power seating system motor (E2310).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation level of 
care. The Plan denied your request. The Plan says the records received does not indicate the enrollee needs an 
intensive therapy program with multiple visits from a rehabilitation physician per week. 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found evaluating therapy notes show good participation and progress with functional tasks and evaluating 
therapists recommend an intensive rehabilitation regimen in an IRF setting thus the enrollee would be expected 
to significantly benefit from and participate in an intensive rehabilitation regimen. IRF criteria 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.