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

 
We decided that the Plan does not have to pay for a PET scan.  
 
You asked the Plan to pay for the PET scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
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 
pay for the PET scan. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the member is only noted to have "memory problems". There was no indication that the member met 
diagnostic criteria for either, let alone both AD and FTD. Without this first requirement for coverage having 
been satisfied, it cannot be said that the requested service meets Medicare criteria 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pay for a PET scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital inpatient admission provided from June 20, 2022, 
to June 29, 2022.  
 
You asked the Plan to pay for the hospital inpatient admission. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this service was not authorized. 
 
The Plan contract says prior authorization is recommended for inpatient hospital care provided by an out-of-
network provider. 
 
We looked at the file and the Plans rules. The file shows that prior authorization was not obtained. Based on 
this information, we decided that the Plans rules for coverage of the hospital inpatient admission have not been 
met. Therefore, we decided that the Plan does not have to pay for a hospital inpatient admission provided from 
June 20, 2022, to June 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 drugs are not covered when not dispensed through physician's services. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says the IRF services are 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation does not support that you would meet 
criteria for admission to an acute IRF. There is no indication that you would require skilled rehabilitation in an 
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain your functional status.  You 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns on teeth #2, 3, 30 and 31 (D2740). 
 
You asked the Plan to pre-approve crowns on teeth #2, 3, 30 and 31. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers crowns when 
the services are medically necessary and reasonable. 
 
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 crowns on teeth #2, 3, 30 and 31. Our 
reviewer says that the services are medically necessary. Our physician reviewer found a sedative filling was 
placed on tooth #3 on October 10, 2023. From the x-ray, it is noted that there are fractures in the teeth in 
question, and unsupported tooth structure that can continue to fracture. The clinical note states wear/breakage 
on #2/3 and 30/31. There is wear (attrition) on these teeth, but it is also noted that parts of these teeth have been 
fractured. Fractured teeth need to be fixed in order to restore a persons ability to eat. The dental provider also 
noted in their note needs to be restored fairly soon or there is a possibility of fx and loss of teeth. (fx is an 
abbreviation for fracture). Based on the information provided, crowns D2740 on teeth numbers 2,3,30,31 are 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crowns on teeth #2, 3, 30 and 31 have been met. Therefore, we decided that the 
Plan has to pre-approve crowns on teeth #2, 3, 30 and 31 (D2740).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the records provided support the need for a 
home ventilator. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found continuation of the home 
ventilator is not medically necessary. The enrollee has COPD, rheumatoid arthritis, congestive heart failure, 
seizure disorder, and schizophrenia. The enrollee has reportedly had a home ventilator for 6 to 7 years and is 
benefiting from it. However, no compliance downloads are provided in the records. There are no pulmonary 
function tests to assess the severity of the COPD. An arterial blood gas from April 24, 2023, shows a normal 
PaCO2 of 43. If there is prior documentation of chronic carbon dioxide (CO2) retention, the enrollee's 
respiratory needs would likely be met with BiPAP with average volume assure pressure support (AVAPS).  
The records do not show this has been tried as an outpatient. Medicare does not cover a home ventilator when 
used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: 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. The Plan denied 
your request. The Plan says your medical records do not show you have complex rehabilitation needs that 
require frequent evaluation by a rehabilitation doctor and an intensive team.  
 
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 do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation does not support that you would meet 
criteria for admission to an acute IRF. There is no indication that you would require skilled rehabilitation in an 
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain your functional status.  You 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: 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's functional and medical needs require 
close medial management, specialized rehabilitation nursing and intensive therapy to maximize their level of 
independence. The Plan denied your request. The Plan says 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. 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. 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 she would meet criteria for 
admission to an acute IRF. There is no indication that the enrollee would require skilled rehabilitation in an 
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain her 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 right lower extremity revascularization, x-ray of blood 
vessel and x-ray of aorta. 
 
You asked the Plan to pre-approve right lower extremity revascularization, x-ray of blood vessel and x-ray of 
aorta. 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 right lower extremity revascularization, 
x-ray of blood vessel and x-ray of aorta. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the documentation does not 
support the medical necessity of the procedure in question. There is documentation that the symptoms are mild and do not interfere with his daily activities. There is no suggestion in the medical record of limb 
threat. Additionally, the enrollee has an extensive cardiac history with severe heart failure that is limiting the 
enrollees activity with documented dyspnea and fatigue. He has documented residual weakness in the right 
lower extremity from a previous stroke. There is also documentation that the patients inflow anatomy is 
complex due to a dissection in the infrarenal aorta. All these factors suggest that risk of intervention would be 
higher than average for treatment of a non-limb threatening condition with mild symptoms (not limiting his 
activities). The documentation also suggests the enrollee would have a higher-than-average chance of not 
experiencing meaningful improvement in quality of life from the intervention as he is so limited by his heart 
failure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right lower extremity revascularization, x-ray of blood vessel and x-ray of aorta 
have not been met. Therefore, we decided that the Plan does not have to pre-approve right lower extremity 
revascularization, x-ray of blood vessel and x-ray of aorta.
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 from IRF services to gain 
strength, receive intensive therapy, and improve activity tolerance. The Plan denied your request. The Plan says 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. 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. 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 IRF.  There is no indication that the enrollee would require skilled 
rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain their 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: 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 this care to gain a higher level of 
function. The Plan denied your request. The Plan says the enrollee's medical condition does not require IRF 
services, and care can be provided in another setting.  
 
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 do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. 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 she 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 rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (22612) using a Minuteman device. 
 
You asked the Plan to pre-approve spinal surgery using the Minuteman device. You say that the enrollee has 
tried and failed conservative therapies. You say that the enrollee's pain limits their ability to participate in 
normal activities of daily living. You also say that this is the next best step in the enrollee's treatment plan. The 
Plan denied your request. The Plan says this 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 spinal surgery using the Minuteman 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found current evidence-based medical guidelines and peer-reviewed literature do not fully support the interspinous fusion device procedure over the gold standard of 
lumbar fusion. There is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of 
this device for this enrollees medical condition. Fusion indications within guidelines/literature for (existing or 
potential intraoperative) instability have not been documented and/or met in this case. In addition, there are 
multiple alternate pain generators plausibly significantly contributing to the clinical condition that have not 
been fully documented as having been excluded and/or ruled out. There was no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal surgery using the Minuteman device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (22612) using a Minuteman device.