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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's criteria exceeds mobility and ADL criteria for IPR 
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 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: 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 on blood thinners and if there is a fall you 
will bleed out. The Plan denied your request. The Plan says your records do not show that you have complex 
rehabilitation needs that require frequent evaluation by a rehabilitation physician. The Plan says that the 
services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit the most with acute 
inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee does not require complex 
medical management such as extensive wound care or high risk medication changes.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac radiofrequency ablation. 
 
You asked the Plan to pre-approve sacroiliac radiofrequency ablation. You say that sacroiliac radiofrequency 
ablation is medically necessary. The Plan denied your request. The Plan says the requested sacroiliac 
radiofrequency ablation is experimental, investigational, or unproven.  
 
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 sacroiliac radiofrequency ablation. Our 
reviewer says that the requested sacroiliac radiofrequency ablation is not considered medically reasonable and 
necessary in this case. Our physician reviewer found sacroiliac radiofrequency ablation is considered 
experimental therapy because of the wide variation in efficacy reported in the peer reviewed literature. 
Therefore, the request is deemed 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 sacroiliac radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve sacroiliac radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs aggressive inpatient rehabilitation 
to achieve highest level of function. The Plan denied your request. The Plan says the enrollee's condition does 
not meet the Medicare guidelines.  The Plan says that the services needed may be provided safely in a lower 
level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve genicular nerve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the RFA. You say that this is medically necessary for the enrollee's bilateral 
chronic knee pain. The Plan denied your request. The Plan says that this type of injection is considered 
experimental and therefore is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, there were no medical records provided with the case file. We 
requested medical records, but none were received. Without records, we cannot determine that whether the 
requested service is medically necessary. Therefore, we decided that the Plan has to pre-approve genicular 
nerve radiofrequency ablation (RFA).  
 
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 custom fabricated mandibular advancement device 
(E0486). 
 
You asked the Plan to pre-approve the oral device. You say that you are requesting an appeal for the denial of 
pre-authorization. The Plan denied your request. The Plan says under Medicare, the request 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 looked at the file and Medicare rules. The records do not show that the enrollee has hypertension, ischemic 
heart disease, history of a stroke, excessive daytime sleepiness, mood disorders, insomnia or impaired 
cognition for the device. Based on this information, we decided that Medicare rules for coverage of the oral 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom 
fabricated mandibular advancement device (E0486).
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's records do not show that treatments have 
been finished in the current 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 the enrollee is presently receiving appropriate services in the acute care setting. 
Records do not support the need to transfer from one acute hospital to another. Continued care in the short-term 
acute hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient 
rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility.  
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 myocardial perfusion imaging, tomographic (SPECT). You asked the Plan to pre-approve myocardial perfusion imaging, tomographic (SPECT). You say that 
myocardial perfusion imaging, tomographic (SPECT) is medically necessary. The Plan denied your request. 
The Plan says myocardial perfusion imaging, tomographic (SPECT) is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion imaging, tomographic (SPECT) 
is covered when the criteria listed in the Medicare rules section of this decision 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 myocardial perfusion imaging, 
tomographic (SPECT). Our reviewer says that myocardial perfusion imaging, tomographic (SPECT) is not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 
hypertension, chronic atrial fibrillation, no angina, dyspnea on exertion, heart failure, and a normal LV systolic, 
which does not benefit from any type of stress test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging, tomographic (SPECT) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic 
(SPECT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
May 8, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for a urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. 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 pay for the 
urine polymerase chain reaction (PCR) panel rendered on May 8, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate. 
 
You asked the Plan to pre-approve methotrexate. You say that the enrollee has been on this medication since 
October 1, 2023. The Plan denied your request. The Plan says that self-administered drugs do not fall under 
Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve methotrexate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939).  
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the enrollee's pain affects their 
activities of daily living (ADLs) including sleep, hygiene, and walking distance. You say that the enrollee has 
tried and failed multiple conservative treatments for greater than 12 weeks including physical therapy and 
injections. You also say that your recommendation is to proceed with surgical intervention. The Plan denied 
your request. The Plan says this is considered experimental and therefore is not covered. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found bone marrow aspirate remains experimental for use as bone graft material. Therefore, the reviewer found that the bone marrow aspirate is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Susvimo. 
 You asked the Plan to pre-approve Susvimo. You say that Susvimo is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Susvimo have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Susvimo. Our reviewer says that 
treatment with Susvimo is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of Avastin and Lucentis before they will approve the requested drug. The requested 
drug is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Susvimo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Susvimo.
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 it is your professional opinion that the patient will 
receive the appropriate level of care in the acute rehabilitation setting. The Plan denied your request. The Plan 
says based on Medicare guidelines, the IRF services you are requesting 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 the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VivAer Nasal airway remodeling with a radiofrequency 
procedure (30469). 
 
You asked the Plan to pre-approve VivAer. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve VivAer. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found provided medical records and review of the current peer-reviewed medical literature do not 
document that use of the VivAer Nasal airway remodeling with radiofrequency procedure has been shown in controlled studies in a CMS-approved journal to result in long term health benefits in patients with nasal valve 
stenosis with trouble breathing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VivAer have not been met. Therefore, we decided that the Plan does not have to 
pre-approve VivAer Nasal airway remodeling with a radiofrequency procedure (30469).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve procedure (64624).

You asked the Plan to pre-approve a genicular nerve procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a genicular nerve procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure at this time. It is the subject of ongoing clinical trials. Therefore, the request is deemed 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 a genicular nerve procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve procedure (64624).