Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient stay for an approved surgery. 
 
You asked the Plan to pre-approve the inpatient stay. You say that the inpatient stay is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. The procedure can be 
performed in the outpatient setting. 
 
The Plan follows Medicare rules. Medicare rules say that an inpatient admission is generally appropriate when 
the admitting physician expects the patient to need hospital care that crosses at least two midnights. 
 
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 inpatient stay. Our reviewer says 
that the inpatient stay is not medically necessary. Our physician reviewer found the procedure is not an 
inpatient only procedure. The procedure is currently approved as an ambulatory procedure. The records do not 
show any reason the physician would expect the admission to last at least two midnights. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an inpatient stay for an approved surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
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 kyphoplasty is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documented trial of a back 
brace for this enrollee. The criteria for coverage are not met and the services are not medically necessary 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 a kyphoplasty.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG) brain positron emission 
tomography (PET) scan.  
 
You asked the Plan to pre-approve the FDG PET scan. You say that this imaging was medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 FDG PET scan. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that there is no diagnosis or clinical 
evidence of Frontotemporal Dementia. The review has determined that the NCD criteria for coverage have not 
been met. 
 
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 FDG PET scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fluorodeoxyglucose (FDG) brain positron emission tomography (PET) scan.
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 would like to go to an IRF to regain your 
independence and go home safely. The Plan denied your request. The Plan says an IRF admission 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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 are requesting reconsideration based on medical 
necessity. The Plan denied your request. The Plan says the request for inpatient rehabilitation admission 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH stay is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for LTACH 
stay. 
 
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 more stable and improving 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT) (77014, 
77385, G6002, G6015). 
 
You asked the Plan to pre-approve IMRT. You say that the requested therapy is needed for the treatment of the 
enrollee's breast cancer. The Plan denied your request. The Plan says there is no high-quality evidence that this 
type of radiation therapy is needed or effective for the enrollee's cancer. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from 
high dose exposure. IMRT generally implies inverse planning algorithms, i.e., the physician determines radiation treatment parameters to maximize dose to the target and minimize dose to normal tissues, and the 
planning algorithm maximizes the adherence to these parameters by modifying the beam spatially and/or 
temporally. However, this enrollee is not being offered whole breast radiotherapy but rather partial breast 
radiotherapy. Notably, the prescribed dose is not the typical accelerated partial breast fractionation of 5-10 
fractions, but rather the 15-fraction regimen used in IMPORT LOW. For IMRT to be medically necessary, an 
appreciable benefit must be achieved. IMRT can be considered medically necessary when a clinically 
meaningful reduction in normal tissue dose exposure can be achieved. For this enrollee, there is no plan 
comparison demonstrating the need for IMRT or plausible rationale for the need of IMRT. The decision is 
unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity modulated radiation therapy (IMRT) (77014, 77385, G6002, G6015).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital care. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital care. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says the records do not show that the 
enrollee had thoughts and plans to harm himself or others, delusion or hallucinations. The enrollee does not 
meet criteria for approval. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital care. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found based upon review the 
records provided, it was not expected this enrollee would improve in a reasonable period of time as he did not 
have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any 
behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, 
perceptual disturbance including delusions, auditory or visual hallucinations. The health plans denial of 
inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental 
health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not 
appear that active treatment was taking place. It did not appear that the services were reasonably expected to 
improve the enrollees condition or for the purpose of diagnosis. The reviewer is unable to find an 
individualized treatment plan, however, the entire record is not present. It did appear that the records were 
supervised and evaluated by a physician. The enrollee does not meet criteria for acute inpatient mental health 
treatment as he was not shown to be a danger to himself or others, no auditory or visual hallucinations. He is 
noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve a Freestyle Libre 3. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre 3. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the enrollee qualifies for a CGM. He 
should have one that alerts him to low blood glucose (bgs) since he is having many of them. The Dexcom g6 or 
g7 would suffice; libre 3 only recently became covered on Medicare plans so he should be provided a CGM like libre 3 (or Dexcom g6 or g7or libre 2) since all of these will alert him of low bgs so he can eat and /or 
adjust his insulin doses and avoid severe hypoglycemia. 
 
We looked at this physician's review, the file, and Medicare rules. The Freestyle Libre 3 is now a covered 
device, as it has been assigned the covered code of E2103 as of June 15, 2023. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre 3 have been met. Therefore, we decided that the 
Plan has to pre-approve a Freestyle Libre 3.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (T4523).  
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the requested supplies are not a Medicare covered 
benefit and do not meet the Medicare definition of durable medical equipment. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (T4523).
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 meets IRF admission criteria. The Plan 
denied your request. The Plan says the request 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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spine fusion (22558), arthrodesis, anterior 
interbody technique, including minimal discectomy to prepare interspace (22585), anterior instrumentation 
(22845), and autograft for spine surgery only (20937).  
 
You asked the Plan to pre-approve the surgical services. You say that the enrollee is bent over. You say that the 
enrollee is unable to daily living self-care or activities at this point. You also say that x-rays have been 
included. 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 surgical services. Our reviewer says 
that the requested surgical services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records do not document spinal instability fracture or lesion. Therefore, the reviewer found that the requested fusion is not medically reasonable or 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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar spine fusion (22558), arthrodesis, anterior interbody technique, including 
minimal discectomy to prepare interspace (22585), anterior instrumentation (22845), and autograft for spine 
surgery only (20937).
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 IRF services to regain your prior level of 
functioning and independence. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a waterjet ablation procedure (0421T). 
 
You asked the Plan to pre-approve the ablation procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that this procedure is covered when there is a maximum 
urinary flow rate (Qmax) of less than or equal to 15 mL/s (voided volume greater than 125 cc). 
 
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 ablation procedure. Our reviewer 
says that this procedure is not medically necssary. Our physician reviewer found the records do not show the maximum urinary flow rate. Without this information, the procedure is not supported. 
 
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 ablation procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a waterjet ablation procedure (0421T).