Persius/hicric huggingface dataset:
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 member exceeds the criteria for an 
appropriate LTACH admission. The Plan denied your request. The Plan says the member is receiving 
appropriate in-patient acute care and is currently unstable for 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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The requested service cannot be recommended as 
the elements of the coverage rules are not satisfied. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home international normalized ratio (INR) device. 
 
You asked the Plan to pre-approve a home INR device. You say that it takes four to five days for lab results. 
You say that by that time you could bleed internally due to thinning of blood or cause a heart attack due to not 
enough blood going to your heart. The Plan denied your request. The Plan says a home INR device is not 
covered if you have not been on anticoagulant therapy for at least three months. 
 The Plan follows Medicare rules. Medicare rules say that the use of home PT/INR monitoring may be covered 
for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial 
fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism) on 
warfarin when certain criteria have been 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 home INR device. Our reviewer says 
that the requested home INR device is not medically necessary. Our physician reviewer found that the provided 
documentation does not support that the enrollee has completed anticoagulant therapy for at least three months. 
Therefore, the reviewer found that the requested device is not medically reasonable or 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 a home INR device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home international normalized ratio (INR) device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Via Disc NP allograft injection. 
 
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 requested allograft injection is 
considered experimental for the treatment of back pain. 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 NP allograft injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
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 proton beam therapy 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 records do not contain 
documentation showing which organs or tissues would receive a clinically meaningful benefit from proton 
beam therapy. There is no clear physician documentation of the stage and other factors of your diagnosis or 
documentation of the range of therapy choices. The criteria for coverage are not met and the services are 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 proton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
foot orthotics to be provided by an out-of-network (OON) provider.
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 member's current physical and occupational 
deficits require and would benefit from an IRF admission. The Plan denied your request. The Plan says the 
member does not meet the Medicare criteria for an IRF admission. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 26, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve advanced foot-ankle feature and shock reducing pylon. 
 
You asked the Plan to pre-approve advanced foot-ankle feature and shock reducing pylon. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prosthesis and additions are only covered for certain 
indications. 
 
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 advanced foot-ankle feature and shock 
reducing pylon. Our reviewer says that the documentation does not support that the requested items are 
medically reasonable or necessary. Our physician reviewer found you have had an amputation below the knee 
since 2013. You use a prosthesis to do activities of daily living and walk for exercise. You do not have 
vocational or other activities requiring a K3 prosthesis. While the documentation shows that you have potential 
to be a K3 ambulator, you are not. Therefore, you do not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of advanced foot-ankle feature and shock reducing pylon have not been met. 
Therefore, we decided that the Plan does not have to pre-approve advanced foot-ankle feature and shock 
reducing pylon.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a positron emission tomography (PET) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the services 
requested are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 positron emission tomography (PET) 
scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found the criteria 
for approval have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a positron emission tomography (PET) scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
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 proton beam therapy 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 records do not demonstrate that 
standard dosimetric constraints cannot be met with a non-proton-based treatment (with the comparison plans 
showing rectal and bladder constraints being readily met and penile bulb constraint not show), and it is not 
plausible that proton therapy would be needed to meet these constraints. 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 proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc allograft procedure (0627T). 
 
You asked the Plan to pre-approve VIA Disc allograft procedure. You say that the enrollee has tried and failed 
conservative therapies. You also say that this procedure is necessary for the enrollee. The Plan denied your 
request. The Plan says the requested procedure 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 VIA Disc allograft procedure. Our 
reviewer says that the requested VIA Disc allograft procedure is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the injection of VIA Disc into the spinal disc for advanced 
degenerative disc disease is being requested against Food and Drug Administration (FDA) approval guidelines. 
The reviewer found that large well-designed studies in the peer review scientific literature comparing stand-alone use of VIA Disc to established treatments are needed. Published studies do not demonstrate any long-
term health outcome advantage with the use of VIA Disc NP as an alternative to standard treatments. 
Therefore, the reviewer found that the requested VIA disc allograft 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 VIA Disc allograft procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve VIA Disc allograft procedure (0627T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facial laceration repair. 
 
You asked the Plan to pre-approve the requested services. 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 the requested services. Our physician 
reviewer found that the enrollee has a chin scar since childhood and desires scar revision. The record provided 
does not indicate that the requested service is required for the repair of accidental injury or for the improvement 
of the functioning of a malformed body member or that there is functional impairment. 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a facial laceration repair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging (MPI) (78452). 
 
You asked the Plan to pre-approve an MPI. The Plan denied your request. The Plan says Medicare criteria is 
not met. The Plan also says that the enrollee's records do not indicate they have cardiac symptoms or 
abnormalities on cardiac testing and physical examination. 
 
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 an MPI. Our reviewer says that there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing in this 
enrollees clinical management. Our physician reviewer found the enrollee is asymptomatic. There is no 
documentation that the electrocardiogram shows an uninterpretable pattern or that the enrollee is unable to 
exercise. There is no evidence provided that would support the need for radionuclide stress testing 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 an MPI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a myocardial perfusion imaging (MPI) (78452).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gammagard. 
 
You asked the Plan to pre-approve gammagard. You say that the requested drug is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 gammagard. Our reviewer says that the 
requested drug, gammagard, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Therefore, the reviewer found that the requested drug 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 gammagard have not been met. Therefore, we decided that the Plan does not 
have to pre-approve gammagard.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that 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 
 
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's 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (ImpediMed's L-Dex 
device) (93702). 
 
You asked the Plan to pre-approve ImpediMed's L-Dex device. You say that the enrollee is at high risk of 
developing lymphedema, and you believe the use of ImpediMed's L-Dex device is medically necessary. The 
Plan denied your request. The Plan says the requested service 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 ImpediMed's L-Dex device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current literature on this device does not provide sufficient supportive 
evidence that this method of screening is more effective than other standard screening methods leading to 
improved overall outcomes. Higher quality studies are needed. Our reviewer found that this enrollee is not 
participating in a clinical trial for this device. Our physician reviewer found that therefore, the bioimpedance 
spectroscopy will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ImpediMed's L-Dex device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bioimpedance spectroscopy (ImpediMed's L-Dex device) (93702).