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 the enrollee needs the IRF services to return to a 
prior level of function. The Plan denied your request. The Plan says the IRF requirements have not been met.  
 
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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different 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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the notes do not show that the enrollee must have an intensive therapy 
program in order to improve self-care functioning.  
 
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 provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that 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. Therefore, the reviewer found that the requested IRF 
admission 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 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: 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 to be in a live-in facility that 
provides the care that is critical for the enrollee's survival. The Plan denied your request. The Plan says the 
enrollee's condition does not meet the requirements for an inpatient stay in a skilled nursing facility. 
 
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 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. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs are custodial and can be provided 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 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 arthrodesis (22612) and posterior non-segmental 
instrumentation (22840). 
 
You asked the Plan to pre-approve arthrodesis and posterior non-segmental instrumentation. You say that this 
is medically necessary. The Plan denied your request. The Plan says the Medicare criteria for reasonable and 
necessary are not met because use of this device as a stand-alone procedure has not been shown to be safe and 
effective in long term studies. 
 
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 arthrodesis and posterior non-segmental 
instrumentation. 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. The HA Minuteman G3-R MIS Fusion Plate is intended for 
use with bone graft material and is not intended for stand-alone use. In addition, 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. No 
compelling rationale is 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 arthrodesis and posterior non-segmental instrumentation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve arthrodesis (22612) and posterior non-
segmental instrumentation (22840).
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 to an IRF is medically necessary. The 
Plan denied your request. The Plan says you do not meet the Medicare 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 rehabilitation therapy services can be delivered in a wide variety of settings across 
the care continuum.  Post-acute settings differ in the types of available rehabilitation therapies, intensity of 
therapy, and the level of medical and nursing support. Acute inpatient rehabilitation facilities are settings were 
complex medical needs and functional needs combine. The requirements for admission to an inpatient 
rehabilitation facility (IRF) include a need for 24-hour rehabilitation nursing care, a minimum of three 
physician face-to-face visits per week and a minimum of three hours of therapy daily at least five days per 
week (or at least 15 hours over a seven-consecutive day period).  Additionally, an individual requires multiple 
types of therapies one of which should be physical or occupational therapy. 
In this case, 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 doesnt support that you would meet criteria for 
admission to an acute inpatient rehabilitation facility. 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 her 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show 30 days of wound measurement, and they show devitalized 
tissue in the wounds. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical documentation supports that this enrollee has suffered with lower extremity ulcerations 
since October 2023. As of January 3, 2024, the medical documentation supports that the enrollee continues to 
suffer with lower extremity grade 3 ulcerations with exposed bone. They have attempted conservative 
treatments including routine and standard wound care. They have had a vascular workup, have been on oral 
antibiotics, and receive debridement and dressing changes. Medicare advises that hyperbaric oxygen is 
recommended for diabetic wounds of the lower extremities in patients who have type I or type II diabetes with 
lower extremity wounds, a wound classified as a Wagner grade 3 or higher, and the patient that has failed an 
adequate course of standard wound therapy which is generally greater than 30 days. The medical 
documentation supports that this patient meets the above-mentioned criteria, therefore the requested hyperbaric 
oxygen therapy for the lower extremity bones should be considered 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 services have been met. Therefore, we decided that the Plan has to pre-
approve hyperbaric oxygen therapy.  
 
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 peripheral artery revascularization of the lower 
extremities (37229, 37228, 37227, 37225, 37224, 37220). 
 
You asked the Plan to pre-approve peripheral artery revascularization of the lower extremities. You say that 
this is medically necessary. The Plan denied your request. The Plan says the records do not show that the 
enrollee has evidence of an anatomically suitable lesion for intervention based on the sonography results.  
The Plan follows Medicare rules. Medicare rules say that this item or service is 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 peripheral artery revascularization of 
the lower extremities. Our reviewer says that the enrollee does not meet criteria for coverage. Our physician 
reviewer found there is no documentation that the patient is having symptoms consistent with lifestyle limiting 
claudication or limb threat. No pulse examination is provided. There is a lower extremity duplex ultrasound 
report demonstrating no evidence of segmental occlusive disease with ankle-brachial indexes (ABI) of 0.7 
bilaterally. Merely having moderately diminished ABIs is not, in itself, an indication for intervention. There is 
no narrative of an indication or treatment 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 peripheral artery revascularization of the lower extremities have not been met. 
Therefore, we decided that the Plan does not have to pre-approve peripheral artery revascularization of the 
lower extremities (37229, 37228, 37227, 37225, 37224, 37220).
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 enrollee has completed their acute care 
phase and is ready to begin their recovery phase at the LTACH. The Plan denied your request. The Plan says 
enrollee's care can continue to be provided in the current inpatient 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 enrollee is a 65-year-old male who was admitted to the acute care hospital with 
pneumonia, COPD exacerbation, and acute respiratory failure requiring high flow oxygen support, steroids, 
bronchodilators, antibiotics, and thoracentesis. Recent notes describe the enrollee is now afebrile without leukocytosis but still dependent on high flow oxygen support and BiPAP at night. The enrollee appears to still 
be unstable and requires additional acute care hospital services that can safely be provided at the current facility 
until more stable and appropriate for transfer. The enrollee does not require services at the LTACH that are not 
already available at the current facility. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as 
the enrollee is not yet stable for transfer and as it would not be clinically advantageous. Completion of 
treatment at the current facility is recommended.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full-length hospital bed rails (E0310). 
 
You asked the Plan to pre-approve full-length hospital bed rails. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that side rails (E0305, E0310) or safety enclosures 
(E0316) are covered when they are required by the beneficiary's condition and they are an integral part of, or an 
accessory to, a covered hospital bed. 
 
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 full-length hospital bed rails. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the bed rails are not 
appropriate for the enrollee's condition. Bed rails used as restraints are associated with high rate of injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of full-length hospital bed rails have not been met. Therefore, we decided that the 
Plan does not have to pre-approve full-length hospital bed rails (E0310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options/accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no medical need for the multiple power options available with the 
requested wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
provided records do not support that the patient is high risk for skin breakdown and is unable to perform a 
functional weight shift (the patient is able to walk short distances and rise from a chair using her upper 
extremities for support), has a history of pressure ulcer(s) or has had skin flap surgery. The records do not 
document the patient performs bladder self-catheterization and is unable to transfer independently or that the 
patient has increased muscle tone or spasticity to meet criteria for the power tilt and recline and thus the 
multiple power option base. As the requested wheelchair base does not meet Medicare coverage criteria, the 
requested accessories are not covered. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with multiple power options/accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis sacroiliac (SI) joint (27279). 
 
You asked the Plan to pre-approve arthrodesis SI joint. You say that this is medically necessary. 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 arthrodesis SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding imaging or radiographic evidence 
supporting a sacroiliitis pathology. There is no clear history of SI joint pain onset or failure of conservative 
treatment directed to the SI joint. Multiple other plausible pain generators including at the lumbosacral spine 
are evident. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is 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 arthrodesis SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve arthrodesis sacroiliac (SI) joint (27279).