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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollee is medically stable as described above and does not need physical 
medicine and rehabilitation (PMR) physicians supervision 3 times a week in an IRF. No acute rehab nursing 
needs documented. At the current functional level, the enrollee needs routine physical therapy (PT), 
occupational therapy (OT) and does not need intensive therapies consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach in an IRF. 
Document does not support necessity for admission to an IRF. The complexity of the enrollees medical, rehab, 
and nursing needs (combined complexity does not require acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. IRF admission is not necessary and is not reasonable. The 
enrollees rehab needs can be safely provided in an alternate and low intensity setting such as in a skilled 
nursing facility (SNF).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you had an adverse reaction to methotrexate. The Plan 
denied your request. The Plan says the Plan requires a trial of an oral and injectable bisphosphonate before it 
will approve Prolia. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that you do 
not meet criteria for a step therapy exception for Prolia. Our physician reviewer found you have not tried and 
failed an oral and injectable bisphosphonate. The record does not show that these drugs would likely be less 
effective and/or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Prolia.
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 the enrollee needs the LTACH services 
to regain maximum functioning. The Plan denied your request. The Plan says the LTACH services are 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 is receiving appropriate care at the acute care facility being provided by 
the Plan. The documentation does not support the need for LTACH services. 
 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 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 of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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. 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says you 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found The Plan erred in its denial of IRF admission. 
 
Per Medicare Benefit Policy Manual Ch 1, 110, and 42 CFR 412.622, the medical record overall complies with 
the various documentation requirements for IRF admission (e.g., as best summarized by the physical therapy 
(PT) note from October 19th, 2023 and hospitalist note from October 26th, 2023). Indeed, your condition is in 
fact 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 PT, occupational therapy (OT), speech-language pathologist (SLP), 
physician oversight of 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollee is medically stable as described above and does not need physical 
medicine and rehabilitation (PMR) physicians supervision 3 times a week in an IRF. No acute rehab nursing 
needs documented. At the current functional level, the enrollee needs routine physical therapy (PT), 
occupational therapy (OT) and does not need intensive therapies consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach in an IRF. 
Document does not support necessity for admission to an IRF. The complexity of the enrollees medical, rehab, 
and nursing needs (combined complexity does not require acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. IRF admission is not necessary and is not reasonable. The 
enrollees rehab needs can be safely provided in an alternate and low intensity setting such as in a skilled 
nursing facility (SNF).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tempus xF liquid biopsy testing. 
 
You asked the Plan to pre-approve liquid biopsy testing. You say that this is needed to maintain your health. 
The Plan denied your request. The Plan says the documentation does not justify why this testing is needed. 
 
The Plan follows Medicare rules. Medicare rules state that next generation sequencing tests may be covered if 
certain indications 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 liquid biopsy testing. Our reviewer says 
that you do not meet criteria for this testing. Our physician reviewer found you have prostate adenocarcinoma. 
The notes do not indicate whether this is a somatic or inherited cancer and there is no documentation to 
demonstrate staging or if this is a refractory or recurrent cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of liquid biopsy testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Tempus xF liquid biopsy testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration because 
you are oxygen dependent, and you cannot go home without a ventilator. The Plan denied your request. The 
Plan says the request is not medically necessary because the records show that the ordered settings for the 
noninvasive ventilator show it is going to be used only in a bi-level pressure mode.  
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have end-stage COPD, although 
pulmonary function test results are not provided. You were recently hospitalized with pneumonia and a COPD 
exacerbation. Arterial blood gas (ABG) was consistent with severe acute on chronic hypercarbic respiratory 
failure. You improved on BiPAP and other therapies. The pulmonary consultant recommended BiPAP as an 
outpatient. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. You may benefit 
from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient. Medicare 
does not cover a home ventilator when used at settings that can be provided with BiPAP. The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair with multiple 
power option (K0862) and additional items and accessories (codes E2363 x2, E1028 x2, E2377, E2313, E1007, 
E1012, E2311, E0955, and E1028). 
 
You asked the Plan to pre-approve a Group 3 heavy duty power wheelchair and additional items and 
accessories. You say that you would like this case to be reviewed and considered for approval to help the 
enrollee obtain a much-needed power wheelchair for independent mobility. The Plan denied your request. The 
Plan says the notes do not show that the enrollee meets the rules for a Group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0862) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 heavy duty power wheelchair 
and additional items and accessories. Our reviewer says that the requested Group 3 power wheelchair with 
power tilt and recline and power elevating leg rests is not medically necessary. Our physician reviewer found 
the enrollee requires a power wheelchair for mobility and accomplishing their daily activities. However, the 
clinical documentation is insufficient why a lower-level power wheelchair would not suffice for their needs 
versus a Group 3 power wheelchair. Our reviewer found that there is inadequate clinical documentation 
regarding why the enrollee requires power tilt and recline and cannot perform pressure relief. The enrollee has 
no history of skin breakdown, their sensation is intact, and they have good sitting balance. Our physician 
reviewer also found that the enrollee does not require a complex Group 3 power wheelchair base, which is used 
for patients with total paralysis, such as with spinal cord injury.  
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 Group 3 heavy duty power wheelchair and additional items and accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 heavy duty 
power wheelchair with multiple power option (K0862) and additional items and accessories (codes E2363 x2, 
E1028 x2, E2377, E2313, E1007, E1012, E2311, E0955, and E1028).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx UTI-ABR Molecular Test Panel provided on 
May 31, 2023, and billed with codes 87481, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the Altru Dx UTI-ABR Molecular Test Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Altru Dx UTI-ABR Molecular Test Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Altru Dx UTI-ABR 
Molecular Test Panel provided on May 31, 2023, and billed with codes 87481, 87653, 87798, and 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trimming of dystrophic nails provided on July 10, 2023. 
 
You asked the Plan to pay for trimming of dystrophic nails. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for trimming of dystrophic 
nails provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thoracic ESI. 
 
You asked the Plan to pre-approve a thoracic ESI. You say that the procedure is medically necessary for the 
enrollee's current condition. The Plan denied your request. The Plan says the requested procedure does not 
meet the criteria for approval. 
 
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 thoracic ESI. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no advanced imaging of the thoracic spine submitted for review, and a radicular 
pain pattern is not documented. 
 
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 thoracic ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a thoracic ESI.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollee is medically stable with no acuity and no recent hospitalization and does 
not need physical medicine and rehabilitation (PMR) physicians supervision 3 times a week in an IRF. No 
acute rehab skilled nursing needs identified or documented. At the current functional level, the enrollee needs 
routine physical therapy (PT) and occupational therapy (OT) for prosthetic training, and the enrollee does not 
need specialized intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week 
with multidisciplinary approach in an IRF. Document does not support necessity for admission to an IRF. IRF 
Admission is not necessary and reasonable. With no medical complexity, no rehab nursing needs, and current 
functional level as described above does not require IRF stay. The enrollees rehab needs can be provided in an 
alternate and low intensity setting such as continued in a skilled nursing facility (SNF) or continued services at 
home.  
 
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.