Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior tibial nerve stimulation (PTNS). 
 
You asked the Plan to pre-approve PTNS. You say that posterior tibial nerve stimulation is needed to improve 
the patient's urge incontinence. The patient has a risk of polypharmacy due to the multiple medications she is 
taking. The Plan denied your request. The Plan says the patient does not meet criteria for posterior tibial nerve 
stimulation because they have not tried and failed anticholinergic drug therapy. 
 
The Plan follows Medicare rules. Medicare rules say that PTNS  is only covered when the patient's medical 
records document failed standard anticholinergic drug therapy or that the patient demonstrates intolerance to 
the anticholinergic drug therapy despite best attempts at management of the most common side effects of such 
therapy, such as dry mouth and constipation. 
 
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 PTNS. Our reviewer says that the 
patient does not meet coverage criteria for PTNS. Our physician reviewer found the patient is an 83-year-old 
female with urge incontinence, vaginal atrophy, and nocturia. The records do not show that the patient has 
received any other treatments for her condition.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PTNS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve posterior tibial nerve stimulation (PTNS).
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's records do not 
show that they need continued treatments and care that can only be given in a hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 services will provide the enrollee with continued 
medical and pain management while providing the therapy services needed. The Plan denied your request. The 
Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 is medically stable. The enrollee does not need specialized and intensive 
therapies. The enrollee's rehab needs are more appropriate for an alternate and low intensity setting such as in 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 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 a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that a semi-electric hospital bed is 
medically necessary due to traumatic subdural hemorrhage. The Plan denied your request. The Plan says the 
documentation does not indicate that the member requires frequent and immediate need for a change in body 
position. As a result, the requirements for coverage of a semi-electric hospital bed have not been met.  
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that a semi-electric hospital bed is not medically necessary. Our physician reviewer found 
although the patient does require positioning of the body not feasible in an ordinary bed and the patient needs 
to avoid quick positional changes that add to his vertigo and falls, the medical records do not document that  
the patient's condition requires special attachments that cannot be fixed and used on an ordinary bed.  
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you are dependent on oxygen. The Plan denied 
your request. The Plan says the use of a BiPAP has not been found ineffective. 
 
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. 
 
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 ventilator. Our physician reviewer 
found that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode, which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with 
AVAPS and a back-up rate. The provided records do not document trial and failure of a BiPAP device.  
Ventilators used to provide BiPAP therapy for conditions are not reasonable and necessary. The provided 
records do not provide adequate detailed information to meet Medicare criteria for coverage of a ventilator 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that there is no imaging on file that shows any 
stenosis of the spine, but the secondary insurance gave an approval.  The Plan denied your request. The Plan 
says that  an epidural steroid injection is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 injection. Our reviewer says that the 
enrollee does meet the coverage criteria. Our physician reviewer found that the enrollee meets the criteria for a 
trial of epidural steroids. The cervical disc bulge and the thoracic disc pathology can cause significant pain. 
Therefore the request is 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 the injection have been met. Therefore, we decided that the Plan has to pre-
approve an epidural steroid injection.  
 
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: 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 you are experiencing weakness and would like 
therapy to regain strength to return home. The Plan denied your request. The Plan says the SNF services you 
are requesting do not meet the requirements for approval. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a subcutaneous cardiac rhythm monitor 
(implantable loop recorder [ILR]) (33285). 
 
You asked the Plan to pre-approve the ILR device. You say that this is medically necessary due to atrial 
fibrillation and premature ventricular contractions (PVCs). The Plan denied your request. The Plan says the 
enrollee is documented to be asymptomatic. The Plan also says there is no history of syncope or cryptogenic 
stroke in the setting of known or suspected atrial fibrillation. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found here is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an ILR. Therefore, the reviewer found that the the requested ILR device 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 ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of a subcutaneous cardiac rhythm monitor (implantable loop recorder [ILR]) 
(33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx (81551) provided on February 13, 2023.  
 
You asked the Plan to pay for ConfirmMDx. You say that this test is standard of care for the management of 
men at risk for undetected prostate cancer. The Plan denied your request. The Plan says criteria is not met as 
there is no consideration for repeat biopsy based on subsequent PSA and/or DRE testing as recommended by 
consensus guidelines.  
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the 
Medicare rules section of this letter 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 pay for ConfirmMDx . Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the enrollee does not meet criteria for 
molecular testing as outlined in the LCD. This testing was 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 ConfirmMDx have not been met. Therefore, we decided that the Plan does not 
have to pay for ConfirmMDx (81551) provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that proton beam radiation is 
medically necessary. Since the patient requires treatment to the pelvic lymph nodes, proton therapy will afford 
a better opportunity to cover the clinical target volumes while minimizing dose to the adjacent bowel and 
bladder. The Plan denied your request. The Plan says the use of proton-beam radiation therapy has not been 
established for the post-operative treatment of prostate cancer. 
 
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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found proton therapy for prostate cancer is not experimental, and in fact is an accepted treatment approach.  While proton therapy is not an experimental therapy, any potential benefit or 
detriment of proton therapy over standard intensity-modulated radiation therapy (IMRT) is an investigational 
question. Other treatment approaches are also highly effective and well tolerated.  Thus, whether proton 
therapy affords a benefit over other standard approaches for prostate cancer is an area of investigation and 
remains controversial. To date, there are no compelling data to suggest that proton therapy is superior to or 
more beneficial than IMRT or image-guided radiation therapy. The generally accepted standard of care for 
prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service March 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that the panel will be useful for patients at initial 
diagnosis or with refractory disease. The Plan denied your request. The Plan says the test does not meet the 
requirements for approval. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. In this case, there are insufficient medical records to show the stage of 
cancer and a treatment plan for the enrollee. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
the panel testing billed for date of service March 3, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing, coded 0037U, billed for date of service April 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test identifies possible treatment options. 
The Plan denied your request. The Plan says that the information does not indicate advanced or metastatic 
cancer. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the services by a contract provider. The file does not show that the plan provided 
notice that the billed services would not be covered. Under Medicare rules, this means the billed services is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the lab testing, coded 
0037U, billed for date of service April 3, 2023.  
 
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: 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 suffered a stroke and need rehab to return to 
normal daily living. The Plan denied your request. The Plan says 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 your nursing, medical and rehabilitation needs does not require an 
acute 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, and an intensive 
rehabilitation therapy program. 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. There is not a reasonable expectation that you 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drug, self-administered, Mounjaro injection. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
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 the drug, self-administered, 
Mounjaro injection.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.