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

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861) and related accessories and features. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options and related 
accessories and features. You say that the requested items are a medical necessity for the enrollee. The Plan 
denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 3 power wheelchair with 
multiple power options and related accessories and features. Our reviewer says that the requested items are not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee 
requires a power wheelchair for mobility and accomplishing daily activities. However, the provided clinical 
documentation is insufficient why a lower-level power wheelchair would not meet the enrollees needs versus a 
group 3 power wheelchair. There is inadequate clinical documentation regarding why the enrollee requires 
power tilt and recline and cannot adequately perform pressure relief. There is no history of skin breakdown. 
There is a lack of documentation regarding the range of motion and muscle tone in the extremities and why the 
enrollee requires power-elevating leg rests. 
 
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 power wheelchair with multiple power options and related accessories and features have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair with multiple power options (K0861) and related accessories and features.
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 the enrollee needs to be in a rehabilitation facility 
because of debility from just having surgery for hip abductor muscle repair and is still in need of extended 
therapy. The Plan denied your request. The Plan says the enrollee's condition does not meet all of the 
requirements for inpatient rehabilitation admission. The Plan says services may be provided at a lower level of 
care. 
 
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 enrollee's medical records overall significantly complies with the various documentation 
requirements for IRF admission. The enrollees condition is in fact complex, and there is every reason to expect 
participation in and benefit from IRF-level services to include at minimum physical and occupational therapy, 
physician oversight of wound care and polypharmacy, and case manager coordination of any additional 
services that might be needed to make a sustainable return home, as well as avoid preventable re-admissions to 
the acute hospital. 
 
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 you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement, however, the 
documentation does not support that she would meet criteria for admission to an acute inpatient rehabilitation 
facility. The enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 minimally invasive fusion of the sacroiliac joint. 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that the enrollee would benefit from this 
surgery. The Plan denied your request. The Plan says there are no neurologic deficits. 
 
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 sacroiliac joint fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding imaging or radiographic evidence 
supporting a sacroiliitis pathology. Multiple other plausible pain generators including at the lumbosacral spine 
are evident. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a minimally invasive fusion of the sacroiliac joint.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the right total shoulder replacement surgery (23472-
RT). 
 
You asked the Plan to pre-approve the service. You say that the shoulder surgery is medically necessary. The 
Plan denied your request. The Plan says  the total shoulder replacement surgery 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. Formal physical therapy has not been clearly documented 
to have been tried and failed. Additionally, the provided computed tomography from October 5, 2023, noted mild supraspinatus and infraspinatus muscle atrophy, likely related to a chronic rotator cuff tear; however, does 
not clearly demonstrate an irreparable cuff tear. There is no indication that there has been a previous rotator 
cuff repair or attempted repair of the right shoulder. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested right reverse total shoulder replacement surgery 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the right total shoulder replacement surgery (23472-RT).
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 will not get the proper medical care at a 
skilled nursing facility . You say that by going to acute rehab the doctors will be able to treat the enrollee's 
health care needs. 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 the enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can 
receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 504 units of home health aide services. 
 
You asked the Plan to pre-approve the home health aide services.. You say that it is medically necessary for the 
enrollee to receive the number of units being requested due to their medical conditions. The Plan denied your 
request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
provided records in this case do not document a complexity of the enrollee's conditions such that the skills of a 
professional home health aide are required beyond the hours of service already approved by the health plan.  
 
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 home health aide services. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 504 units of home health aide 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 needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement, however, the documentation 
does not support that he would meet criteria for admission to an acute inpatient rehabilitation facility. The 
enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 MyoPro. 
 
You asked the Plan to pre-approve MyoPro. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested device 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 MyoPro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had a stroke in 2018 resulting in left upper extremity partial paralysis. The enrollee 
has tried and failed physical and occupational therapy. The MyoPro Orthosis is not known to be effective, 
based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The 
MyoPro is not the standard of care for this enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device 
will increase participation in bimanual activities. Therefore, the enrollee does not meet criteria for the requested 
device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MyoPro.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve the dental service. You say that the requested realignment procedure is for a 
functional purpose and comfort, not a cosmetic purpose. The Plan denied your request. The Plan says this is not 
a covered benefit under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive orthodontic treatment of the adult dentition (D8090).
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's treating physician states the IRF care is 
medically necessary. The Plan denied your request. The Plan says the IRF care is not medically necessary, and 
the enrollee's needs can be met at a lower level of care such as a skilled nursing facility  
 
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. The enrollee's 
medical status does not require intensive rehabilitation physician or  nursing oversight in an IRF. The enrollee's 
functional level does not require treatment by multiple therapies including physical or occupational therapy in 
an intensive rehabilitation program in an IRF. While the enrollee may benefit from additional rehabilitation  the 
documentation does not reveal that an intensive IRF program of rehabilitation is 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 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 enrollee has complex issues that 
require an LTACH level of care The Plan denied your request. The Plan says the enrollee is receiving 
appropriate in-patient acute care and does not require transfer 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 the enrollee appears to be unstable and requires additional acute care services that can 
safely be provided at the current facility until more stable and appropriate for transfer. Transfer to the LTACH 
is not medically necessary, as it would not be clinically advantageous at this time. Completion of treatment at 
the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on May 18, 2023. 
 
You asked the Plan to pay for the podiatry services. You say that you would like this claim reconsidered. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for podiatry services provided on May 18, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 skilled nursing home health visits. 
 You asked the Plan to pre-approve the skilled nursing home health visits. You say that the medical records 
provided support the need for the services in dispute. The Plan denied your request. The Plan says the services 
are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing home health visits. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
that the provided records do not document any acute or unstable medical conditions or changes in medication 
or treatment which would necessitate skilled nursing visits. Records do not document the need for intravenous 
medications, new tube feeding, ostomy care or complex wound care. The unavailability of a competent person 
to provide a non-skilled service, regardless of the importance of the service to the enrollee, does not make it a 
skilled service when a nurse provides the service. 
 
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 skilled nursing home health visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 7 skilled nursing home health visits.