Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) of the chest, abdomen, and pelvis 
with a tertiary level provider. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request for follow-up CT scans can be done with a community level provider, 
since the procedure is for surveillance purposes only. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that due to the complexity of the enrollee's health record, the request for the CT of the chest, abdomen 
and pelvis should be approved to be done at the tertiary care center. The difficulty here is the necessity to be 
able to duplicate the exact scanning technique and to be able to readily compare the serial imaging studies side 
by side to determine any change. In the enrollee's best interest, the requested CT scans should be performed a 
the tertiary care facility so the treating doctors can make certain the serial scans have the same technique and 
can be readily compared. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) of the chest, abdomen, and pelvis with a tertiary level provider.  
 
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 a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the ventilator is required to decrease 
the work of breathing and improve pulmonary status. You say that an interruption of respiratory support could 
lead to serious harm, decline in health status, worsening of condition, increase risk of increasing carbon dioxide 
retention, untimely readmission, or death for the enrollee. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary for this patient because their needs can be met with an alternative device 
such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has COPD and has a report of a BiPAP use along with oxygen support in the hospital providing sufficient 
respiratory stability. Although the enrollee's treating physician has recommended AVAPS, a home ventilator is 
not medically necessary for the enrollee because AVAPS can be provided with an alternative device such as a 
BiPAP device with AVAPS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1845). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show recent injury or surgery, or knee instability. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the clinical documentation indicates that the enrollee received a knee injection with steroid 
medication. The enrollee was noted to have a normal range of motion that was painful. There is no laxity or 
subluxation, or instability noted. Lachman and anterior drawer testing were negative. The clinical 
documentation provided does not support the need for a knee orthosis. The enrollee has a medical history of 
left knee osteoarthritis and pain. However, the physical examination does not demonstrate knee instability and 
there is no indication of recent trauma or surgery. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1845).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA disc allograft.  
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the VIA disco allograft is considered 
experimental in nature. More research is needed to support its use. The services are therefore 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 a VIA disc allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has severe COPD with chronic 
hypercapnic respiratory failure. The device is medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for approval of the ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD with 
repeated hospitalizations for respiratory exacerbations, with arterial blood gas (ABGs) consistent with acute on 
chronic hypercarbic respiratory failure. The enrollee has improved on BiPAP in the hospital. There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. This enrollee may benefit from BiPAP with 
average volume assured pressure support (AVAPS) during sleep as an outpatient. The records do not show this 
has been tried as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. The denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (64555). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says there is not enough medical proof that shows the safety 
and/or success of this service. 
 
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 outpatient procedure. Our reviewer 
says that the requested percutaneous implantation of neurostimulator (PNS) electrode array is not considered 
medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental 
therapy for Complex regional pain syndrome. Therefore, the reviewer found that the requested PNS is not medically reasonable and 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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve 
(64555).
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says admission to an LTACH is not medically necessary. 
 
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 services are not considered to be medically necessary in this case. Our physician 
reviewer found the enrollee is receiving appropriate care in the current setting as provided by the Plan. The 
documentation provided does not support that LTACH services are 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis, sacroiliac (SI) joint, percutaneous (LinQ 
implant) (0775T). 
 
You asked the Plan to pre-approve the service. You say that the enrollee's physician states that the LinQ 
implant is a safe and effective treatment for the enrollee's suffering with pain originating from the sacroiliac 
joint and meet all of the requirements for reasonable and necessary procedures. The Plan denied your request. 
The Plan says the LinQ implant requested does not meet the requirements for approval. 
 
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 there is no SI joint instability fracture or lesion. SI joint fusion for degenerative back pain is experimental. 
 
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 arthrodesis, sacroiliac (SI) joint, percutaneous (LinQ implant) (0775T).
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 will require extensive 
rehabilitative therapies to regain their strength and functional quality of life. The Plan denied your request. The 
Plan says it is not safe for the enrollee to leave the hospital at this time because they have not finished their 
hospital treatments. 
 
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 is receiving appropriate care in the current acute care setting provided by 
the Health Plan. Documentation does not support that LTACH services are medically appropriate 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac computed tomographic angiography (CTA) 
(75574). 
 
You asked the Plan to pre-approve the service. You say that the CTA should be approved. The Plan denied 
your request. The Plan says the CTA 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 service. Our physician reviewer 
found the clinical guidelines for the use of CTA have not been met based on review of the submitted clinical 
documentation. As a result, at this time CTA imaging would not be considered medically reasonable and 
necessary in this enrollee's 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cardiac computed tomographic angiography (CTA) (75574).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair with tilt in space. 
 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 a manual wheelchair with tilt in space is covered 
when specific criteria are met. The rules say that for equipment to be covered, it must be appropriate and 
needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. 
 
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 advanced functional 
decline and lives in a nursing facility. He does not require tilt and recline for positioning. The criteria for 
coverage are not met and the manual wheelchair is not reasonable or 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. Furthermore, the file shows that the enrollee 
lives in a skilled nursing facility (SNF) and Medicare does not cover durable medical equipment in a SNF. 
Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair with tilt in space.
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 benefit for a short stay of 
rehabilitation to get back to baseline prior to going home. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about the enrollee's condition, they do not meet all of the 
requirements.  
 
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 per Chapter 1 as the enrollee is deconditioned following an acute illness and able to 
walk at a household level. The enrollee does not require intensive or complex rehabilitation and does not 
require frequent physiatry oversight.  
 
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: 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 you do not feel at baseline, and you could benefit 
from more therapy before returning home. The Plan denied your request. The Plan says the request for a skilled 
nursing facility is not medically necessary. 
 
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 and/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: 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 cannot go to a nursing home because you want 
to get stronger. The Plan denied your request. The Plan says based on Medicare guidelines, 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 you were admitted for surgical repair of a hip fracture after a fall. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.