Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT) services.  
 
You asked the Plan to pre-approve the IGRT services. You say that IGRT is medically necessary and the most 
appropriate treatment for their condition.  The Plan denied your request. The Plan says picture studies are not 
supported to guide the enrollee's type of treatment.  
 
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 IGRT services. Our reviewer says 
that IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer found 
using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is approved 
by the Food and Drug Administration (FDA) for use with ultrasound. However, that in and of itself does not 
mean that daily imaging is necessary. It simply means that the device was designed to incorporate this 
functionality. Therefore, to bill for daily simple simulations and/or IGRT for a technology for which need has 
not been established by published data or supported by consensus guidelines (many of which recommend 
against treatment with these devices in general) is not necessary.  IGRT in this case would not be furnished in accordance with accepted standards of medical practice.  
 
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 IGRT services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve image guided radiation therapy (IGRT) 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 need physical and occupational therapy and pain 
management to assist in regaining function, mobility and strength in your right hip. The Plan denied your 
request. The Plan says you do not meet 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 complexity of your 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (99214, 96138). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that this is medically necessary. The 
Plan denied your request. The Plan says psychological testing requires a clinically trained examiner. All 
psychological tests should be administered, scored, and interpreted by a trained professional such as a clinical 
psychologist, psychologist, advanced nurse practitioner with education in this area, or a physician assistant who 
works with a psychiatrist with expertise in the appropriate area. Testing conducted when no mental 
illness/disability is suspected would be considered screening and would not be covered. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing can be 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 neuropsychological testing. Our 
reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found the case file 
does not contain documentation that the enrollee has deficits on standard mental status testing or clinical 
interview, and that a neuropsychological assessment is needed to establish the presence of abnormalities or 
distinguish them from other disease processes. In addition, there is no documentation that any of the other 
medically necessary indications for this testing are met in this case. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (99214, 96138).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary for the enrollee 
to receive the therapy services needed and improve their quality of life. The Plan denied your request. The Plan 
says the enrollee is currently not stable for transfer to a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says you must have a 3-day inpatient qualifying hospital stay before going into 
SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that physical therapy helps improve your 
chronic back pain. The Plan denied your request. The Plan says the request is not reasonable and necessary. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for your condition. 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/or deliver a program to maintain your current condition or to prevent or slow 
further deterioration. You have had extensive prior therapy and instruction in a home exercise program. The 
requested additional therapy sessions do not require the skills of a professional therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had a stroke and cannot move your arms and 
require IRF services. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral L4-5 and L5-S1 medial branch blocks. 
 
You asked the Plan to pre-approve the medial branch blocks. You say that the enrollee needs the injection in 
order to improve their condition. The Plan denied your request. The Plan says the requested procedure is not 
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 pre-approve the medial branch blocks. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there were no imaging studies of 
the lumbar spine available that revealed lumbar facet arthropathy/hypertrophy and to rule out other causes of 
pain. On physical examination, facet mediated pain was suggested by pain with extension. There was no 
documentation of tender lumbar facet joints and positive lumbar facet loading. A standard of care is the failure 
of at least three months of conservative/conventional therapies before consideration of an interventional 
procedure such as facet injections. There was no documentation of failure of conservative therapies, such as 
physical therapy and an ongoing home exercise program.  
 
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 medial branch blocks have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bilateral L4-5 and L5-S1 medial branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy (NPWT). 
 
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 NPWT 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 the enrollee has a diagnosis of a 
diabetic foot wound. The records do not document the enrollee has been on a comprehensive diabetic 
management program and reduction in pressure on a foot ulcer has been accomplished with appropriate 
modalities. The criteria for coverage are not met and the NPWT is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve negative pressure wound therapy (NPWT).
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 is a fall risk and requires rehabilitation. 
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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 an IRF 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support necessity for an admission to an IRF. The 
complexity of the enrollee's medical, rehabilitation, and nursing needs (combined complexity) does not require 
an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. Our 
reviewer also found that the enrollee's rehabilitation needs can be safely provided in an alternate and low 
intensity setting such as in an 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraperitoneal nutrition (IPN) (84193, 84185, 84189, 
84197, 84199, 84224). 
 You asked the Plan to pre-approve IPN. You say that the enrollee's oral intake is incapable of meeting one 
hundred percent (100%) of his nutritional needs while balancing the protein losses due to peritoneal dialysis. 
The malnutrition is not due to a clinical malabsorption state but to his ongoing condition and comorbidities. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of IPN. 
 
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 IPN. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has malnutrition in the setting of end stage renal 
disease. The record provided does not document that enteral nutrition has been considered and ruled out, tried 
and been found ineffective, or that enteral nutrition exacerbates gastrointestinal tract dysfunction. The 
documentation must show that the enrollee must have (a) a permanent condition involving the small intestine 
and/or its exocrine glands which significantly impairs the absorption of nutrients or (b) disease of the stomach 
and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported through and 
absorbed by the gastrointestinal (GI) system. The elements of the coverage criteria are not satisfied. The 
requested service is not 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 IPN have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intraperitoneal nutrition (IPN) (84193, 84185, 84189, 84197, 84199, 84224).
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 your request for admission to an IRF cannot be 
approved at this time. 
 
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. 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.