Persius/hicric huggingface dataset:
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 unable to walk. The Plan denied your 
request. The Plan says the Inpatient Rehabilitation Facility services requested do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Computed Tomography Face/Sinuses without contrast (70486). 
 
You asked the Plan to pre-approve a Computed Tomography. You say that  The Plan denied your request. The 
Plan says that the appeal was misdirected and therefore the decision was not rendered within the specified time 
frame. 
 
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. Our reviewer 
says that you need this medical item. Our physician reviewer found a sinus CT scan is reasonable and 
necessary as defined by Social Security Act, Section 1862 (a)(1)(A) due to the enrollee's symptoms, signs, and 
possible need for sinus 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 a Computed Tomography have been met. Therefore, we decided that the Plan 
has to pre-approve a Computed Tomography Face/Sinuses without contrast (70486).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint Peripheral Nerve Stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the SPRINT PNS System. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this service 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 SPRINT PNS System. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this service is considered 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 SPRINT PNS System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Sprint Peripheral Nerve Stimulator (PNS) (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 the enrollee has not walked in 3 months 
and needs more aggressive treatment such as physical therapy, occupational therapy, and speech therapy. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements for an LTACH 
admission.  
 
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 that all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 7 home health physical therapy visits 
 
You asked the Plan to pre-approve the additional home health services. The Plan denied your request. The Plan 
says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional home health services. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
the enrollee does not have documented ongoing skilled physical therapy needs. The enrollee is ambulating 100 
feet and requiring her prior level of assistance. 
 
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 additional home health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an additional 7 home health physical therapy visits
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 requires inpatient level of care due to 
concurrent active medical issues to receive maximum optimization. The Plan denied your request. The Plan 
says the services requested is not supported based on the records received. 
 
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. 
 
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 Contour test strips. 
 
You asked the Plan to pre-approve Contour test strips. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that only the preferred brand products listed 
in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic testing supplies. Therefore, we decided that the Plan does not have to pre-approve Contour test 
strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing provided 
on November 9, 2021.  
 
You asked the Plan to pay for the urine PCR testing. You say that  this testing was medically necessary. The 
Plan denied your request. The Plan says experimental procedures are not covered by the enrollee's plan. 
 
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 pay for the urine PCR testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that a review of the medical literature in clinical practice guidelines indicate that 
standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine culture and 
susceptibility studies. In addition, there is lack of support for the clinical utility of large multiplex PCR urinary 
tract infection panel tests.  
 
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 urine PCR testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) testing provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block (64454) completed on June 23, 2022, 
and genicular nerve radiofrequency ablation (RFA) procedure (64624) completed on August 18, 2022. 
 
You asked the Plan to pay for a genicular nerve block and RFA. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the 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 pay for a genicular nerve block and RFA. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found genicular nerve blocks and genicular nerve ablation are considered 
investigational and not medically necessary for the treatment of chronic 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 genicular nerve block and RFA have not been met. Therefore, we decided that 
the Plan does not have to pay for a genicular nerve block (64454) completed on June 23, 2022, and genicular 
nerve radiofrequency ablation (RFA) procedure (64624) completed on August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (K0806). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you need a power scooter with an 
oxygen tank carrier. The Plan denied your request. The Plan says that a new power scooter is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs (K0806) have added capabilities 
that are not needed for use in the home. 
 
We looked at the file and Medicare rules. The requested POV has added capabilities that are not needed for use 
inside your home. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power operated 
vehicle (K0806).
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 the enrollee needs physical therapy and 
occupational therapy and is a fall risk and needs to be monitored. The Plan denied your request. The Plan says 
that the enrollee does not need therapy or nursing services every day that are only on an inpatient basis. 
 
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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs (K0739) and replacement tires 
(E2374). 
 
You asked the Plan to pre-approve the wheelchair repairs and replacement tires. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says the power 
wheelchair has exceeded its reasonable useful lifetime. 
 
The Plan must follow Medicare rules. Medicare rules say that the RUL of durable medical equipment (DME) is 
determined through program instructions. In the absence of program instructions, carriers may determine the 
RUL, but in no case can it be less than five years.  
 
 
 We looked at the file and Medicare rules. The record shows this request is for repairs on a backup power 
wheelchair that the enrollee received in August 2017. This power wheelchair has exceeded its RUL. Therefore, 
we decided that the Plan does not have to pre-approve power wheelchair repairs (K0739) and replacement tires 
(E2374).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric hospital admission 
from June 10, 2023, forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee remains at 
high risk. The Plan denied your request. The Plan says the enrollee's records do not show that active treatment 
is being provided for a new (acute) condition. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric care. 
Our reviewer says that the service is not medically necessary from June 10, 2023, forward. Our physician 
reviewer found that it did not appear that active treatment was taking place beyond the date in question. It did 
not appear that the services were reasonably expected to improve the enrollees condition or for the purpose of 
diagnosis beyond the date in question. Based upon review the records provided for the admission of this 
enrollee does not meet the criteria for June 10, 2023, forward as this enrollee was not shown to be a danger to 
self or others, delusions, auditory or visual hallucinations noted. The enrollee was cooperative/compliant with 
treatment while not showing any threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continued inpatient psychiatric hospital admission from June 10, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vacuum Assisted Socket System (VASS) (L5781). 
 
You asked the Plan to pre-approve a VASS. You say that the enrollee requires complete replacement of their 
existing prosthesis. The Plan denied your request. The Plan says this request exceeds the enrollee's need and 
does not meet the Medicare criteria of reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a VASS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of an L5781 vacuum assisted suspension system for residual limb volume management 
and moisture evacuation systems among lower extremity amputees is unproven and not medically necessary 
due to insufficient evidence of safety and/or efficacy. Our reviewer also found that the physician 
documentation does not support the need for the elevated vacuum suspension system. 
 
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 VASS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Vacuum Assisted Socket System (VASS) (L5781).
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 the PET scan. The Plan denied your request. The Plan says the medical 
records provided do not indicate that the enrollee meets the diagnostic criteria of both Alzheimer's disease and 
frontotemporal dementia. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record provided does not document 
that the enrollee meets the diagnostic criteria of both Alzheimer's disease and frontotemporal dementia. 
 
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 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: 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 needs continued 
rehabilitation along with an intensive level of care which is offered by a long-term acute care hospital and 
remains too weak to be discharged home. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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.