Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized scooter. 
 
You asked the Plan to pre-approve a motorized scooter. You say that you need the scooter to get around and get 
to the store. The Plan denied your request. The Plan says you have no medical need for a scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
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 motorized scooter. Our reviewer says 
that you do not meet the criteria for coverage. Our physician reviewer found the documentation available for 
review does not support that you require a power mobility device to accomplish mobility related self-care tasks 
in the home. Our reviewer also found that there is no indication that you are unable to use an alternative 
assistive device. 
 
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 motorized scooter have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a motorized scooter.
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 you are requesting a fast appeal as the 
enrollee currently meets acute LTACH hospital admission criteria. 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 with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer to a lower level of care. 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 at this time 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion with an inpatient admission. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documented spinal 
instability in the submitted records. The requested fusion is not reasonable or medically necessary for the 
enrollee 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar fusion with an inpatient admission.
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 the injection. You say that the enrollee does have lower back pain that 
radiates into both hips with numbness and tingling in their right left to their knee. The Plan denied your request. 
The Plan says an epidural steroid injection 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 injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has a history of 
chronic low back pain due to lumbar spondylosis. and has tried Tramadol, Tylenol, oral steroids, and anti-
inflammatories. However, there is no documentation of an in-person clinical evaluation being done that 
documents a history, physical examination, and concordant radiological image based diagnostic testing that 
would support the medical necessity. Therefore, the procedure is 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 the 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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF 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 the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. 
 
While the member may continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement, the documentation does not support that they would meet criteria for 
admission to an IRF. There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours per week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain their functional status. 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 an 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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
guidelines for services in 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 the enrollee does not have complex or intensive rehabilitation needs. The enrollee is 
minimal assistance to stand-by assistance for function, ambulation and transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records support the need for the IRF 
admission.  The Plan denied your request. The Plan says the notes do not show that the enrollee's care 
specifically requires the involvement of a doctor in the field of rehabilitation medicine. The enrollee's medical 
and therapy needs could be met in a skilled nursing unit.  
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical management of knee revision surgery. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this admission. The Plan denied your 
request. The Plan says based on Medicare guidelines and the information we have about your condition you do 
not meet all of the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
non-operative management of L2 compression fracture and left anterior tibialis partial tear and were discharged 
to a skilled nursing facility on August 4, 2023. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support 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 you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records support the need for the IRF 
admission. The Plan denied your request. The Plan says based on Medicare guidelines and the information we 
have about the enrollee's condition they do not meet all of the requirements  
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. the complexity 
of the enrollees nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee has a history of subacute rehabilitation admission 
and was discharged home on July 3, 2023. There is ongoing weakness. Medical problems are stable. There are 
no complex nursing or rehabilitation needs. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your recovery would be much quicker in an IRF.  
The Plan denied your request. The Plan says the IRF services requested do not meet the requirements for 
approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity your nursing, medical, and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. 
 
While you may have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement, the documentation does not support that you would meet criteria for admission to an IRF. There 
is no indication that you would require skilled rehabilitation in an IRF, participating in rehabilitation services 
15 hours per week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your 
functional status. 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 an IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that you cannot perform this treatment on 
yourself and without this treatment you would need to seek relief from the emergency room. The Plan denied 
your request. The Plan says you can transition into a home exercise program.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and deliver a program to maintain your current condition 
or to prevent or slow further deterioration. You have had extensive prior therapy and instruction for an in-home 
exercise program. The requested additional therapy sessions do not require ongoing skilled professional 
therapist supervision. 
 
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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a pneumatic compression 
device (E0651, E0667). 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says other in-network providers are unable to provide this specific specialized equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome.   
 
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 referral. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found an in-network provider is available and has been identified. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an out-of-network referral for a pneumatic compression device (E0651, E0667).
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 intensive rehab to help with daily 
function and reduce fall risk. 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. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.