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

 
We decided that the Plan does not have to pre-approve methotrexate tablets. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee needs the medication for 
hyperglyceridemia treatment. 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 methotrexate tablets.  
 
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 VIA Disc NP procedure. 
 
You asked the Plan to pre-approve the VIA Disc NP procedure. You say that you recommend this procedure 
for the enrollee to address pain and restore function. The Plan denied your request. The Plan says the request 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 VIA Disc NP procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the VIA Disc NP procedure is considered experimental/investigational 
and is not medically necessary for the treatment of chronic low back pain. 
 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 VIA Disc NP procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a VIA Disc NP procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services provided on July 23, 2023. 
 
You asked the Plan to pay for the non-emergent services. You say that the enrollee required a higher level of 
care and needed the transportation. The Plan denied your request. The Plan says transport documentation shows 
that the services were provided at the patient's request. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the non-emergent services. Our reviewer 
says that the services were not medically necessary. Our physician reviewer found it was not clear from the 
provided documentation as to why the patient was transported or why the sending hospital was not able to 
continue to treat the patient until appropriate discharge to a lower level of care when ready. The documentation 
does not sufficiently support that other means of transport (such as stretcher van) were contraindicated for this 
patient. 
 
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 non-emergent services have not been met. Therefore, we decided that the 
Plan does not have to pay for non-emergent ambulance services provided on July 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve detoxification services. 
 
You asked the Plan to pre-approve detoxification services. You say that the services are necessary. The Plan 
denied your request. The Plan says the requested facility is not certified or eligible to be certified as a Medicare 
approved facility for the level of care requested. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of detoxification services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve detoxification services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the magnetic resonance imagining (MRI) described by code 70553 
performed on date of service September 18, 2023. 
 
You asked the Plan to pay for 70553. You say that 70553 should be paid as billed because it was medically 
necessary and is supported in the medical record. The Plan denied your request. The Plan says that 70553 was 
not medically necessary as screening tests without a valid medical diagnosis related to the health of the enrollee 
are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 pay for 70553. Our reviewer says that 70553 was 
medically necessary. Our physician reviewer found the MRI in this case was medically necessary because of 
the increased risk central nervous system (CNS) tumors. The records show this enrollee had headaches and was 
diagnosed with Li-Fraumeni syndrome. Li-Fraumeni syndrome (LFS) is a cancer predisposition syndrome 
associated with high risks for a diverse spectrum of childhood-onset and adult-onset malignancies. The lifetime 
risk of cancer in individuals with LFS is greater than or equal to 70% for men and greater than or equal to 90% 
for women. Five cancer types account for the majority of LFS tumors: adrenocortical carcinomas, breast 
cancer, central nervous system tumors, osteosarcomas, and soft-tissue sarcomas.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 70553 have been met. Therefore, we decided that the Plan has to pay for the 
magnetic resonance imagining (MRI) described by code 70553 performed on date of service September 18, 
2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 3, 2023, billed with 
procedure codes 95907-26, 95887-26, 95885-26, and G0453-XU. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is billed with an inappropriate diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that both Electromyography's (EMGs) and Nerve 
conduction studies (NCSs) may be covered if they are billed with a diagnosis that supports medical necessity. 
 
We looked at the file and Medicare rules. The claim was not reported with a diagnosis from the list of 
diagnoses that support medical necessity. Based on this information, we decided that Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on April 3, 2023, billed with procedure codes 95907-26, 95887-
26, 95885-26, and G0453-XU.
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 the denied IRF 
admission. The Plan denied your request. The Plan says criteria for IRF admission have 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 patient's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says IRF care 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 that based on the medical records provided, the enrollee's medical conditions are 
being managed in the nursing facility with no issues that appear to require a physician's evaluation three or 
more times per week in a hospital setting. The enrollee does require physical therapy and occupational therapy 
services, but the medical records provided do not clarify why the enrollee requires an intensive inpatient 
rehabilitation therapy program. There is concern that the enrollee would not be able to fully participate in and 
benefit from the intensive rehabilitation therapy program of at least 3 hours a day, 5 days a week, or 15 hours 
over 7 consecutive days provided in an inpatient rehabilitation facility.  
 
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 home ventilator (E0466).  
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration because 
you need this device to breathe. The Plan denied your request. The Plan says you do not meet criteria for 
approval of a ventilator. 
 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 severe obesity, COPD, 
obstructive sleep apnea untreated, obesity hypoventilation syndrome, coronary artery disease, heart failure with 
preserved ejection fraction, and chronic kidney disease. You were hospitalized in late December 2023, with 
exacerbation of COPD and heart failure, and an elevation myocardial infarction. You improved on BiPAP, but 
treatment of the heart failure was limited by worsening kidney disease. Spirometry, undated, showed a forced 
expiratory volume (FEV1) of 44% of predicted, but was of poor quality. There is no diagnosis of thoracic 
restrictive disease or neuromuscular disease. You may benefit from BiPAP with a volume assurance mode as 
an outpatient. The records do not show this has been tried as an outpatient. Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. 
 
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: 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 this care to regain strength. The 
Plan denied your request. The Plan says medical records do not support the need for an IRF admission and, the 
enrollee needs can be  provided at another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this care is essential for the enrollee. The Plan denied 
your request. The Plan says medical records do not support the need for an IRF admission and, the enrollee 
needs can be safely provided at another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require intense therapy to get stronger and return 
home. The Plan denied your request. The Plan says an IRF admission is not medically necessary, but skilled 
therapies as an outpatient, home with home healthcare, or at a skilled nursing facility (SNF) may be approved 
upon request.  
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. You do 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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee does not meet the Medicare 
criteria for admission to an LTACH care. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to 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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 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 this is medically necessary. The Plan denied your 
request. The Plan says 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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for influenza and urinary tract infection. Medical problems are stable. There are no complex nursing 
or rehabilitation needs.  
 
The patient 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 this patient 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.