Persius/hicric huggingface dataset:
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 lives alone and it is a risk to go home. 
The Plan denied your request. The Plan says the denial of IRF care is correct.  
 
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 can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is 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, but the services required can 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 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: Favorable

 
We decided that the Plan has to pre-approve destruction by neurolytic agent performed with image guidance 
(64635, 64636). 
 
You asked the Plan to pre-approve the radiofrequency ablation (RFA). You say that this is medically necessary 
for the enrollee's pain. The Plan denied your request. The Plan says that the enrollee did not have at least 80% 
pain relief. The Plan also says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the initial thermal radiofrequency ablation (RFA) 
may be considered medically reasonable and necessary after the patient has had at least two medically 
reasonable and necessary diagnostic medial branch blocks (MBBs), with each one providing a consistent 
minimum of 80% sustained relief of primary (index) pain. 
 
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 radiofrequency ablation (RFA). Our 
reviewer says that the requested RFA is not medically necessary. Our physician reviewer found the provided 
documentation indicates the enrollee achieved 80% pain relief from the medical branch blocks (MBBs). 
Therefore, the reviewer found that the requested RFA is 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 the radiofrequency ablation (RFA) have been met. Therefore, we decided that 
the Plan has to pre-approve destruction by neurolytic agent performed with image guidance (64635, 64636).  
 
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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for IRF 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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is 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, but the services required can 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 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 mycophenolate mofetil. 
 
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 medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that prescription drugs used in immunosuppressive therapy 
furnished are covered for an individual who receives an organ transplant for which payment is made under 
Medicare. The drugs requested here are for an organ transplant that was not paid for by Medicare. Therefore, 
we decided that the Plan does not have to pre-approve mycophenolate mofetil.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure (30117, 30469, 30801). 
 
You asked the Plan to pre-approve the VivAer procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. 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 VivAer procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has nasal obstruction and turbinate 
hypertrophy. There is insufficient literature to support the safety and efficacy of the requested service for the 
enrollee's specific conditions. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure (30117, 30469, 30801).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lipid testing provided on May 19, 2023. 
 
You asked the Plan to pay for lipid testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says lipid testing in asymptomatic individuals is considered to be non-covered screening. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, lipid testing, was performed for screening purposes. Medicare does not cover 
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for lipid testing 
provided on May 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on January 12, 
2023. 
 You asked the Plan to pay for paramedic intercept services. You say that you would like reconsideration 
because the requested paramedic intercept services are medically necessary. The Plan denied your request. The 
Plan says these services are not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on January 12, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot be safely discharged home. They 
cannot bend, twist or lift and cannot care for themself. 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 the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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 SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nucynta. 
 
You asked the Plan to pre-approve the medication. You say that Nucynta is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nucynta.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbosacral selective nerve block. 
 
You asked the Plan to pre-approve a lumbosacral selective nerve block. You say that the enrollee suffers from 
gunshot wounds, and the requested procedure being recommended before increasing the fentanyl dosage. The 
Plan denied your request. The Plan says a lumbosacral selective nerve block is only indicated when the 
member has severe degenerative changes of the spine. 
 
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 lumbosacral selective nerve block. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that according to the enrollee's imaging of the lumbar spine submitted, 
the enrollee has mild degenerative changes to the lumbosacral spine. A lumbosacral selective nerve block is 
only indicated when the enrollee has severe degenerative changes of the spine. The review has determined that 
the enrollee does not meet the LCD criteria for coverage. 
 
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 lumbosacral selective nerve block have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbosacral selective nerve block.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Azithromycin. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Azithromycin.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix skin substitute. 
 
You asked the Plan to pre-approve Epifix. You say that the medical records support the medical necessity of 
this treatment. The Plan denied your request. The Plan says the records do not show that the enrollee's wound 
has failed to respond to standard wound care. 
 
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 Epifix. Our reviewer says that the 
requested Epifix skin substitute is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates a stage 3 pressure ulcer of the foot which was 
evaluated by a wound care specialist on September 5, 2023. The reviewer found that the wound was debrided 
with an overall measurement showing approximately a 90% improvement from August to September with current treatment. Epifix skin substitute was requested. However, as the current treatment has shown significant 
improvement without failure of treatment, the criteria for Epifix skin substitute is not met, and would not be 
reasonable or medically necessary at this time 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 Epifix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epifix skin substitute.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says rules for coverage for CPAP have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device beyond the 
first three months of therapy requires that the treating practitioner must conduct a clinical re-evaluation and 
document that the beneficiary is benefiting from PAP therapy.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Specifically, coverage criteria require adherence to PAP 
therapy, defined as use of PAP greater than or equal to 4 hours per night on 70% of nights during a consecutive 
thirty (30) day period anytime during the first three (3) months of initial usage. The provided medical records 
do not support that you have used PAP greater than or equal to 4 hours per night on 70% of nights during initial 
usage. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure 
(CPAP) device (E0601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts/orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts/orthotics (L3020).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care.  
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is demonstrating continual progress and 
may benefit from additional rehabilitation. The Plan denied your request. The Plan says the enrollee's benefit 
for SNF care has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from May 5, 2023, to 
October 29, 2023. The Plan has covered 100 days of SNF care.  
 
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve 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 you need inpatient rehabilitation so you can return to 
your home and full function of life. The Plan denied your request. The Plan says you do not meet Medicare 
guidelines for services in an inpatient rehabilitation 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 medical record overall significantly complies with the various documentation 
requirements for an IRF admission, as best summarized by the occupational therapy note from October 24, 
2023 and the physical therapy note from October 25, 2023. Your condition is complex and fragile, and there is 
every reason to expect that you will participate in and benefit from IRF-level services to include at minimum 
physical and occupational therapy, physician oversight of laboratory values and polypharmacy, and case 
manager coordination of any additional services that might be needed to make a sustainable return home, as 
well as avoid preventable readmissions to the acute hospital. Therefore, the requested inpatient rehabilitation 
facility admission is approved.  
 
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 16 additional home health physical therapy visits. 
 You asked the Plan to pre-approve 16 additional home health physical therapy visits. You say that you need 
longer therapy to continue making progress. 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 16 additional home health physical 
therapy visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found you do not have documented ongoing home health physical therapy needs. You appear to have 
reached a plateau in function.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 16 additional home health physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 16 additional home health physical therapy visits.