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

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty. 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that this service is medically necessary, as 
the enrollee is not seeing improvement with physical therapy. The Plan denied your request. The Plan says this 
procedure is not medically necessary as the enrollee has not failed all conservative care options. 
 
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 total hip arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. The enrollee has tried home exercises; 
however, no formal physical therapy has been documented. The provider noted that physical therapy would not be of benefit with the advanced osteoarthritis noted on imaging. The formal imaging studies were not provided 
for review to corroborate the degree of osteoarthritis in the right hip. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested total hip arthroplasty 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 a total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty.
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 broke your knee cap and require IRF services to 
regain your prior level of functioning. The Plan denied your request. The Plan says the request is not medically 
necessary.  
 
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 at an intensive rehabilitation 
therapy program. Although you continue to have a need for skilled therapy, the documentation does not support 
that you meet criteria for admission to an acute inpatient rehabilitation facility. You can receive further services 
at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 records support that an LTACH level 
of care is appropriate. The Plan denied your request. The Plan says LTACH care 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 has a history of chronic obstructive pulmonary disease (COPD) and 
presented with hip periprosthetic fracture and respiratory failure. The enrollee's fracture has been managed by 
the surgery team. The enrollee required critical care services for high oxygen requirements. The enrollee is 
receiving appropriate care in the current acute care setting. The documentation provided does not support that LTACH services are medically appropriate 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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. 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you would benefit from bilevel positive 
airway pressure (BIPAP) therapy but does not have documented requirements for home ventilator. Hence, you 
do not meet criteria, as best standard of care, for home ventilator given data and documentation. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
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 are medically necessary for the 
enrollee. The Plan denied your request. The Plan says these services are medically necessary.  
 
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 
does not require treatment by multiple therapies or an intensive rehabilitation therapy program. While the 
medical record supports a continued need for skilled therapy, there is no documented need for intensive 
rehabilitation services. The member can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stereotactic Computer-Assisted (Navigational) 
Procedure (61783). 
 
You asked the Plan to pre-approve computer-assisted services with a surgical procedure. You say that this 
procedure is medically necessary. The Plan denied your request. The Plan says use of computer-assisted 
imaging with spinal surgery is investigational. 
 
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 computer-assisted services with a 
surgical procedure. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is no large volume, long-term/high-quality 
clinical studies to confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in lumbar spinal surgeries. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested stereotactic computer-assisted (navigational) procedure 
(61783) 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 computer-assisted services with a surgical procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Stereotactic Computer-Assisted 
(Navigational) Procedure (61783).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ascending aortic aneurysm repair (33858), possible root 
and hemiarch replacement (33863, 33866), possible coronary artery bypass grafting via median sternotomy 
(33533, 33517) and associated inpatient hospitalization. 
 
You asked the Plan to pre-approve surgical services with an inpatient admission. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the records do not show that the 
aneurysm is symptomatic. The Plan says it is not at least 5.5. centimeters (cm) in diameter, and it is not 
growing at a rate that would support repair. 
 
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 surgical services with an inpatient 
admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is asymptomatic, and the documentation 
provided does not indicate that the aneurysm is at least 5.5cm in diameter or that it has been increasing in size 
at a rate that would support repair. As such, guidelines would not support operative repair at this time. In 
summary, repair of the ascending aortic aneurysm, possible root and hemiarch replacement, and possible 
coronary artery bypass grafting via median sternotomy (CPT 33858, 33863, 33866, 33533, 33517) would not 
be considered medically necessary in the clinical management of this 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 surgical services with an inpatient admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ascending aortic aneurysm repair (33858), possible root and 
hemiarch replacement (33863, 33866), possible coronary artery bypass grafting via median sternotomy (33533, 
33517) and associated inpatient hospitalization.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of nonunion or malunion, tibia with iliac or other 
autograft (27724) to be provided by an out-of-network (OON), tertiary care provider. 
 
You asked the Plan to pre-approve the repair of a nonunion or malunion tibia with iliac or other autograft 
provided by an OON tertiary care provider. You say that the enrollee had an open pilon fracture. You say there 
are no network providers willing to take on the severity of the enrollee's injuries after a failure of fixation. You 
also say that you are at the tertiary level of the care center. The Plan denied your request. The Plan says it has 
not been established that the needed care is not available in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 repair of a nonunion or malunion 
tibia with iliac or other autograft provided by an OON tertiary care provider. Our reviewer says that the criteria 
for coverage of OON care have not been met. Our physician reviewer found there is support that the plan's 
denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs 
through referral to in-network orthopedic surgeons. There is no support that the enrollee's condition would 
make it medically necessary to see the OON tertiary care provider. The Plan has shown that they have in-
network providers who meet the Standards of Care required for treatment of the enrollee's condition.  
 
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 repair of a nonunion or malunion tibia with iliac or other autograft provided 
by an OON tertiary care provider have not been met. Therefore, we decided that the Plan does not have to pre-
approve repair of nonunion or malunion, tibia with iliac or other autograft (27724) to be provided by an out-of-
network (OON), tertiary care provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerves (64635, 64636). 
 
You asked the Plan to pre-approve destruction by neurolytic agent. You say that if the enrollee is not seen, they 
will be at risk of being in constant pain and not able to perform activities of daily living. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
 
 The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used).  
 
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 destruction by neurolytic agent. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the LCD requires two 
sets of diagnostic medial branch blocks. There is only one set documented. Therefore, the request is deemed 
not medically reasonable and 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 destruction by neurolytic agent have not been met. Therefore, we decided that 
the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerves (64635, 
64636).
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 rehabilitation in order to improve 
their condition. The Plan denied your request. The Plan says an IRF admission is not medically necessary and 
the enrollee can receive services at 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 enrollee does not require treatment by multiple therapies at an intensive 
rehabilitation therapy program. Although the enrollee continues to have a need for skilled therapy, the 
documentation does not support that they would meet criteria for admission to an acute inpatient rehabilitation 
facility.  The enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 12, 
2023, to May 11, 2023. 
 You asked the Plan to pay for SNF care. You say that the skilled nursing facility services received were 
medically necessary.  The Plan denied your request. The Plan says the enrollee did not require skilled nursing 
facility services. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the documentation provided, the enrollee did not qualify for SNF 
coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented 
skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs were custodial and could, as a practical 
matter, be provided at a lower level of care (ex. home, AL, LTC). 
 
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 pay for skilled nursing facility (SNF) care provided from April 12, 2023, to May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you have debilitating pain and have 
benefited from RFA before to reduce your pain and improve function. The Plan denied your request. The Plan 
says this procedure is not supported by research and is not covered. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this procedure is considered experimental. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA).
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 need IRF services because you need to get the 
strength in your legs built up so you can walk again. The Plan denied your request. The Plan says the records 
do not show you meet the program 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 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 
does not require treatment by multiple therapies or an intensive rehabilitation therapy program. While the 
medical record supports a continued need for skilled therapy, there is no documented need for intensive 
rehabilitation services. The member can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.