Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that skilled physical therapy continues to be 
medically necessary for the enrollee to improve. The Plan denied your request. The Plan says the additional 
physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the Plan approved 12 additional physical therapy visits. Based on 
the enrollee's response and capacity for a home exercise program, 12 additional physical therapy visits are 
consistent with the standard of care. Our reviewer found no additional input from skilled therapist 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health services. 
 You asked the Plan to pre-approve home health services. You say that you feel this is medically necessary. 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the member is 
a 67-year-old female with a medical history including lymphedema, knee pain and previous cellulitis who has 
been receiving home health physical therapy since December 2022. The documentation indicates the member is 
able to ambulate up to 215 feet using a front wheeled walker and can accomplish transfers. She has been 
medically stable. 
 
The member does not require additional skilled rehab services to effectively provide treatment, care, and/or 
services in order to improve the members condition, perform a maintenance program to maintain the 
members condition and/or prevent deterioration. The member has been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the open implantation of neurostimulator electrode 
array; sacral nerve (transforaminal placement) (64581). 
 You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 open transforaminal placement of a neurostimulator electrode array (64581) is not medically necessary 
in this case. The records did not show a 50 percent or greater improvement in voiding symptoms which is 
required for coverage. 
 
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 open implantation of neurostimulator electrode array; sacral nerve (transforaminal 
placement) (64581).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tempus xF targeted genomic sequence analysis panel 
(81455). 
 You asked the Plan to pre-approve the testing. You say that additional testing is medically necessary for this 
enrollee, who has stage 3 lung cancer. The Plan denied your request. The Plan says this test is not medically 
necessary as the enrollee has already had Tempus xT testing for this same cancer. 
 
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 testing. Our physician reviewer 
found the documentation does not support that the Tempus xF targeted genomic sequence analysis panel has a 
Food and Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic, and an FDA-
approved or FDA-cleared indication for use in this enrollee's cancer. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tempus xF targeted genomic sequence analysis panel (81455).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the requested ESI. You say that you feel this should be covered. The Plan 
denied your request. The Plan says the requested epidural steroid injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI may be covered when the prior treatment 
provided at least 50% pain relief for three months. 
 
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 ESI. Our reviewer says 
that the requested ESI is not shown to be reasonable and necessary. Our physician reviewer found the enrollee 
had an epidural steroid injection in January 2023. There is no documentation indicating the enrollee received at 
least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline 
using same scale for at least three months. The review has determined that the requested epidural steroid 
injection meet the Medicare LCD coverage criteria. 
 
 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 ESI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tempus xR targeted genomic sequence analysis panel 
(81456). 
 You asked the Plan to pre-approve the testing. You say that additional testing is medically necessary for this 
enrollee, who has stage 3 lung cancer. The Plan denied your request. The Plan says this test is not medically 
necessary as the enrollee has already had Tempus xT testing for this same cancer. 
 
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 testing. Our physician reviewer 
found the documentation does not support that the Tempus xR targeted genomic sequence analysis panel 
(81456) has Food and Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic, 
and an FDA-approved or -cleared indication for use in this cancer. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tempus xR targeted genomic sequence analysis panel (81456).
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 that the admission to an IRF 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 the review has determined that 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. There 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 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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met 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 an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors. You say that the power wheelchair and accessories are medically necessary. The 
Plan denied your request. The Plan says the notes do not show a medical need to control the power options 
through the joystick. 
 
The Plan follows 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 electronic connection between 
wheelchair controller and two or more power seating system motors. Our reviewer says that this accessory is 
not medically necessary. Our physician reviewer found that the enrollee has adequate strength to manage 
standard switches for power drives. Thus, the electronic connector 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 an electronic connection between wheelchair controller and two or more power 
seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the medication is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the medication. Our physician reviewer 
found there is no documentation of an inadequate response to at least three (3) months of conservative therapy. 
The review has determined that the documentation does not support that the Hyalgan is medically reasonable 
and necessary for the enrollee. The documentation does not support that the Hyalgan is safe and effective for 
the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyalgan (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve the requested CGM. 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 follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the requested CGM. Our reviewer says 
that the documentation does not support that the coverage criteria are met. Our physician reviewer found the 
record indicates that the enrollee has diabetes. The record provided indicates that the enrollee is being treated 
with insulin. The record provided is insufficient to establish that the requested service is required to improve 
glycemic control or that the provider ordered the requested device. The elements of the coverage criteria 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 requested CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 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 the 
enrollee would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication 
that the enrollee would require skilled rehabilitation in an IRF, participating in rehabiliation services 15 hours a 
week, under the supervision of a physician with at least three (3) visits weekly to regain or maintain the 
enrollee's functional status. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the requested ESI. You say that it is felt that this ESI is needed. The Plan 
denied your request. The Plan says the requested epidural steroid injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs may be covered when the criteria listed in the 
Medicare rules section 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 the requested ESI. Our reviewer says 
that the requested ESI is not medically necessary. Our physician reviewer found the cervical magnetic 
resonance imaging (MRI) does not show any disc protrusion at C7-T1 level nor any facet joint issues at that level. The MRI does show mild right neural foraminal impingement at C5-C6, but injection at that level has not 
been requested. The review has determined that the requested C7-T1 ESI does not meet the Medicare LCD 
coverage criteria. 
 
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 ESI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an epidural steroid injection (ESI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that this service was reported correctly and is 
supported in the medical record. The Plan denied your request. The Plan says payment for code 0245U is 
bundled into payment for code 0018U. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 0245U 
is a column II code to column I code 0018U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 0245U billed for date of service February 24, 
2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda to be used in combination with bevacizumab and oral 
cyclophosphamide. 
 
You asked the Plan to pre-approve Keytruda. You say that there is compelling data to support a highly 
meaningful benefit from therapy with pembrolizumab, bevacizumab, and oral cyclophosphamide. The Plan 
denied your request. The Plan says that the criteria for medical necessity have not been met and coverage 
cannot be provided for Keytruda infusions. 
 
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 Keytruda. Our reviewer says that 
Keytruda is medically reasonable and necessary for the enrollee. Our physician reviewer found in the phase 2 
non-randomized clinical trial, the combination of pembrolizumab with bevacizumab and oral 
cyclophosphamide was well tolerated and demonstrated clinical benefit in 95.0% and durable treatment 
responses (greater than 12 months) in 25.0% of patients with recurrent ovarian cancer. This combination may 
represent a future treatment strategy for recurrent ovarian cancer. Our reviewer also found that although this 
request does not meet compendia and is not FDA approved, it is literature supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda to be used in combination with bevacizumab and oral cyclophosphamide.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional PT sessions. 
 
You asked the Plan to pre-approve 8 additional PT sessions. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 8 additional PT sessions. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that you have chronic pain you are able to manage with a 
home exercise program. The treatment program is effective. You are able to continue with the home program. 
Continued input from a skilled therapist 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 8 additional PT sessions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional PT sessions.