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

 
We decided that the Plan does not have to pre-approve the MyoPro device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is limited evidence for this device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that 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 patient'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. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro device.
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 services are medically necessary for the 
enrollee's care. The Plan denied your request. The Plan says ongoing skilled care can be provided in an 
alternative 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 enrollee does not require treatment by multiple therapies. 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 total knee replacement. 
 
You asked the Plan to pre-approve a total knee replacement. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 total knee replacement. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.Our 
physician reviewer found there is no recent trial of physical therapy for knee 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 a total knee replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee replacement.
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 (tilt, legrest, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that this 
is medically necessary for the enrollee. The Plan denied your request. The Plan says the records do not support 
a need for the requested power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the enrollee is functionally non-ambulatory 
and cannot use a cane or walker for mobility. They cannot functionally propel a manual wheelchair due to 
upper extremity weakness. The enrollee requires a power wheelchair for mobility and accomplishing their daily 
activities. However, the clinical documentation is insufficient why a lower-level power wheelchair would not 
meet the enrollee's needs versus a Group 3 power wheelchair. There is inadequate clinical documentation 
regarding why they require power tilt & recline and cannot adequately perform pressure relief. There is no 
history of skin breakdown. There is insufficient documentation regarding the enrollees graded motor strength 
and range of motion in her upper and lower extremities. There is no significant lower extremity spasticity that 
would necessitate a power elevating foot platform. There is insufficient documentation regarding her level of 
function with regards her level of mobility and ability to perform daily activities. A Group 3 power wheelchair 
base is typically indicated in patients with significant paralysis due to conditions such as a spinal cord injury. 
Therefore, the reviewer found that the requested Group 3 power wheelchair with power tilt & recline, power 
seat elevator, and power elevating leg rests is not 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 a Group 3 power wheelchair with multiple power options 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 (tilt, legrest, seat elevator) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary because your records show you have 
had 2 radiofrequency sessions within the last 12 months which exceeds the Medicare frequency limitations. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency sessions have not been met. Specifically, radiofrequency ablation for the requested 
region has already been performed twice. Therefore, we decided that the Plan does not have to pre-approve 
radiofrequency ablation.
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 to be admitted to an IRF because you 
cannot walk. 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 medically ready to discharge to an Inpatient 
Rehabilitation Facility. The Plan denied your request. The Plan says your condition does not meet all 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 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. The medical records 
support 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. It 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records indicate multiple sources of pain. The Plan also says that 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no magnetic resonance imaging (MR) showing only Modic changes 
without facet degenerative joint disease or stenosis. The reviewer found that the enrollee's cause of pain is not clear. Therefore, the reviewer found that the requested Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure).
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 the full criteria for acute inpatient 
rehabilitation. The Plan denied your request. The Plan says the records do not show the enrollee is able to take 
part in three hours of therapy a day at least five days a week or 15 hours per week. 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 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support 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. It is not a 
reasonable expectation that the enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Zoll heart failure management system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the appropriateness and medical necessity of a Zoll Heart Failure Monitoring System in 
the clinical management of this enrollee. The system is a non-invasive technology for fluid management that 
utilizes a wearable, external sensor which adheres to the chest wall and can assess lung fluid levels. There 
remains a dearth of randomized clinical studies examining long-term clinical outcomes establishing the value of this system in patient management. As a result, at this time the Zoll Heart Failure Monitoring System 
remains investigational and would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Zoll heart failure management system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied CT scan and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the criteria for a CT scan have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pre-approve a computed tomography (CT) scan. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there are no risk factors 
for coronary artery disease and the concern is for palpitations. There is no work-up of heart monitoring. 
 
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 computed tomography (CT) scan have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. You say that the drug shows good response in ovarian cancer. The 
Plan denied your request. The Plan says the drug is not covered for the enrollee's condition.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Enhertu. Our physician reviewer found 
that the enrollee has a diagnosis of stage IV-B, HER-2 positive peritoneal/ovarian cancer. The FDA has not 
stated that the requested drug is indicated for the enrollee's condition.  The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu.
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 (tilt/recline, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee's current chair is 8 years old. You say that the enrollee gets stuck in the house and cannot go outside 
due to the chair not working properly. You also say that with the chair not working properly this can cause the 
enrollee to have pressure sores. The Plan denied your request. The Plan says there is not a medical need for 
multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided records indicate that the 
enrollee has a neurologic disorder with functional deficits. The documentation does not indicate that the 
enrollee has any pressure injuries or requires intermittent catheterization of the bladder or have spasticity that 
would necessitate power tilt or recline. Therefore, the reviewer found that the requested Group 3 power 
wheelchair with multiple power options 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 a Group 3 power wheelchair with multiple power options 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 (tilt/recline, seat elevator) and accessories.
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 LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
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's needs do not meet LTACH admission criteria and it would be 
reasonable to continue her care until she is able to transfer to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic tests. You say that this genetic counseling is recommended. The 
Plan denied your request. The Plan says this testing is considered screening in nature which is not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic tests at issue in this appeal are being requested for screening purposes. Medicare does not cover 
these tests for screening purposes. Therefore, we decided that the Plan does not have to pre-approve genetic 
testing.