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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration for the denial of an LTACH admission. You say this is the safest discharge plan, allowing 
the highest potential for the enrollee's recovery, preventing further deterioration and the best use of medical 
management. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for care 
in 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 the enrollee appears to be improving but is still unstable and requires short-term 
additional acute care services that can safely be administered at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to 
the LTACH would not be clinically advantageous and completion of treatment at the current facility is 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the private room provided from December 9, 2022, to 
December 15, 2022. 
 
You asked the Plan to pay for the private room. You say that you were in the room first, then someone else 
who later tested positive for COVID-19 had moved into your room. You also say that the other person was 
moved out, and you were moved to quarantine status. The Plan denied your request. The Plan says the rules are 
not met, and the private room is not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the private room. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you did not meet criteria for a private room as your health or recovery was not jeopardized and 
you did not require isolation as you were not documented as COVID-19 positive. Our reviewer also found that 
the private room was not medically necessary based on the provided 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 the private room have not been met. Therefore, we decided that the Plan does 
not have to pay for the private room provided from December 9, 2022, to December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a follow-up office visit and labs with the requested 
tertiary level provider. 
 
You asked the Plan to pre-approve a follow-up office visit and labs with the requested tertiary level provider. 
You say that a follow-up office visit and labs with the requested tertiary level provider are medically necessary. 
The Plan denied your request. The Plan says the member does not meet tertiary care guidelines based on 
Medicare Managed Care Manual Chapter 4-Benefits and Beneficiary Protections,110.1 Provider Network 
Standards. Instead, the member was approved for a new patient visit with community level 
gastroenterologist/hepatologist. 
 
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 follow-up office visit and labs with the requested tertiary level provider. Our reviewer says that the requested follow-up office visit and labs with 
the requested tertiary level provider are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that you have hepatitis B cirrhosis. The record provided 
indicates that you are receiving routine outpatient follow up care. 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 a follow-up office visit and labs with the requested tertiary level provider have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a follow-up office visit and labs 
with the requested tertiary level provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that you underwent epidural steroid injection (ESI) at L2-L3 on  
November 17, 2022. You reported an immediate 80% relief from the injection, but the relief was rated as only 
30% on December 29, 2022. You have undergone physical therapy and have also received chiropractic care 
without relief of the back pain. The Medicare LCD coverage criteria requires at least 50% pain relief for three 
(3) months post injection. This has not been achieved and 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met 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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 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 will not make the significant gains 
necessary to be able to stay at home safely if their care is provided at a lower level of care. You also say that 
the enrollee will benefit from inpatient rehabilitation. The Plan denied your request. The Plan says the IRF 
services you are requesting 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found 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. Our physician reviewer also found that 
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 pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the member needs to regain strength but quickly 
gets tired and weak. The Plan denied your request. The Plan says the member has no daily killed nurse or 
therapist needs. 
 
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 based on the documentation provided, the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program 
or to prevent deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, 
can, as a practical matter, be provided 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ILR is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bradycardia and 
dizziness. There is no documentation of a history of unexplained syncope, cryptogenic stroke, or any other 
apparent indication for an ILR. The services are not medically necessary based on the submitted 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot walk more than a few feet without losing 
your breath. You require a continuation of SNF services because you are not ready to be discharged. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have 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 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 a continuation of SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment. The Plan denied your request. The Plan says the basivertebral nerve has not been identified as the 
cause of pain. 
 
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 magnetic resonance imaging (MRI) shows facet degenerative joint disease and spinal 
stenosis. The cause of this enrollee's back pain is unclear. Therefore, the requested service is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator 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. 
 
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 home ventilator. Our physician 
reviewer found the documentation in the medical record does not support that the ventilator at issue is medically necessary and reasonable for this enrollee. It is unclear from the enrollee's records if this ventilator 
will be used exclusively in a setting volume-assured pressure support (VAPS) mode that can be provided by a 
simpler device called a bilevel positive airway pressure (BiPAP) machine. The case file does not contain 
documentation of trial and failure of BiPAP with backup rate and average volume-assured pressure support 
(AVAPS). The documentation is insufficient to support that a home ventilator (E0466) is medically reasonable 
and necessary in this case. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home 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 you believe the enrollee's medical management and 
rehabilitation needs require an inpatient rehabilitation stay and close supervision. The Plan denied your request. 
The Plan says this request does not meet criteria for an IRF 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. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found 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. Our physician reviewer also found that 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a life alert necklace. 
 
You asked the Plan to pre-approve a life alert necklace. You say that you were advised this would be approved. 
The Plan denied your request. The Plan says a life alert necklace is not covered because it is not medical in 
nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a life alert necklace.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ketruda (pembrolizumab) (J9271), Paraplatin 
(carboplatin) (J9045) and Taxol (paclitaxel) (J9267). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the medication is not medically necessary. 
 
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 pre-approve the medication. Our physician reviewer 
found the requested use of the medication is not FDA-approved for the enrollees diagnosis. The use is not 
supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal. This is treated differently than cervix cancer and the 
literature on cervix cancer is not applicable. 
 
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 Ketruda (pembrolizumab) (J9271), Paraplatin (carboplatin) (J9045) and Taxol (paclitaxel) 
(J9267).