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 would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee does not meet functional 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 that the complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. You do not require treatment by multiple therapies. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral cervical facet joint denervation. 
 
You asked the Plan to pre-approve bilateral cervical facet joint denervation. You say that you were told this 
would be covered. The Plan denied your request. The Plan says you have had two radiofrequency ablations 
(RFA) on each side of your neck. You had the right side RFA on 5/11/2023 and 9/19/2023. You had the left 
side RFA on 5/25/2023 and 9/26/2023. Therefore, we are unable to approve the request for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint denervation has a frequency 
limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per 
rolling twelve (12) months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bilateral cervical facet joint denervation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral cervical facet joint denervation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator (E0466) provided on July 20, 2023. 
 You asked the Plan to pay for the home ventilator. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the item was 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 pay for the home ventilator. Our reviewer says that 
the item was not medically necessary. Our physician reviewer found there is no diagnosis of thoracic restrictive 
disease or neuromuscular disease. This enrollee may benefit from BiPAP with volume assurance during sleep 
as an outpatient. The records do not show this has been tried and failed 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pay for the home ventilator (E0466) provided on July 20, 2023.
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 medical records provided support the need for 
the services in dispute. The Plan denied your request. The Plan says that admission to an IRF is not medically 
necessary and does not meet the criteria for coverage. The required services can be provided in an alternate 
setting, such as a skilled nursing facility.  
 
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. There are no complex nursing or 
rehabilitation needs. 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 the enrolleewill 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 Perjeta (pertuzumab). 
 
You asked the Plan to pre-approve Perjeta. You say that this drug is necessary and will aid the enrollee's 
treatment. The Plan denied your request. The Plan says this drug is not medically necessary for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Perjeta. Our reviewer says that the 
criteria for coverage of this drug are not met in this case. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of recurrent breast cancer and is being treated with neoadjuvant therapy with dual HER2 blockade and an aromatase inhibitor prior to surgery. The record provided does not document that the 
enrollee has previously received chemotherapeutic or that the requested drug is being used with chemotherapy. 
The FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved 
cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. No literature from Medicare approved cancer journals were submitted for review. The 
elements of the coverage criteria are not satisfied. The requested service cannot be 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 Perjeta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Perjeta (pertuzumab).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this device is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 a home ventilator is medically necessary. Our physician reviewer found the enrollee has COPD and 
chronic respiratory failure. The enrollee has been on a home ventilator for five years and a change in therapy is 
not the best practice or indicated. The ventilator will not be used as CPAP or BiPAP. The documentation does 
support the medical necessity and rationale for continued home ventilator use. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve a home ventilator (E0466).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat transforaminal epidural steroid injections (ESI) 
(64483, 64484). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the request is medically necessary. You say it 
will cause a great deal of pain to have to wait until March when you would be eligible next. The Plan denied 
your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs are limited to a maximum of four (4) sessions 
per spinal region in a rolling twelve (12) month period. 
 
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 repeat ESI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the criteria state that epidural steroid 
injections are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period. 
You have already had four epidural spinal injections in the same anatomic area in the past year. Additionally, 
the latest progress note on October 24, 2023 does not clearly indicate subjective findings of radiculopathy in 
the proposed area of injection, and the exam does not support evidence of radiculopathy. The documentation 
does not reveal physical examination evidence of detailed motor, sensory, reflex testing or provocative spine 
maneuvers (i.e., straight leg raise testing) that support a radiculopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat transforaminal epidural steroid injections (ESI) (64483, 64484).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Wendler glottoplasty. 
 
You asked the Plan to pre-approve a Wendler glottoplasty. You say that you are having difficulty speaking. 
You say that you are unable to control your voice. You also say that you were injured during a previous surgery 
and it is not healing. The Plan denied your request. The Plan says this is considered cosmetic 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 a Wendler glottoplasty. Our reviewer 
says that the requested Wendler glottoplasty is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided records do not indicate that the requested Wendler glottoplasty 
meets all Medicare criteria for medically reasonable and necessary and safe and effective for the patient. The provided records in this case do not document that the procedure is being performed to treat an illness or injury 
or to improve the functioning of a malformed body member. Therefore, the reviewer found that the requested 
procedure 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 a Wendler glottoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Wendler glottoplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's 
medical needs are being met in the current acute setting. The LTACH would add no additional services. With 
additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of 
care can be determined. 
 
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's wound care is not complex. Her needs are met in her current setting, with no therapeutic advantage to transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651). 
 
You asked the Plan to pre-approve a PCD. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 PCD. Our reviewer says that the item 
is not medically necessary. Our physician reviewer found the enrollee was not documented as failing full 
conservative treatment efforts or with documented objective benefit with the pneumatic compressor to justify 
this request. 
 
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 PCD have not been met.  Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (PCD) (E0651).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks (64454 x 2). 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that you paid $2,000 for a nerve block. You 
also say that because the nerve block did work, the doctor wants to do the full procedure and burn the nerve. 
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 genicular nerve blocks. Our reviewer 
says that the requested genicular nerve blocks are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the use of genicular nerve blocks are considered experimental/ 
investigational. There are ongoing clinical trials of these procedures.  Therefore, the reviewer found that the 
requested genicular nerve blocks are 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 genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve blocks (64454 x 2).
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 condition does not meet all the 
requirements. The Plan says services may be provided in another setting, an acute rehabilitation facility, skilled 
nursing facility, nursing facility, outpatient setting or home care. 
 
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 making progress and is not expected to require 25 days of care for 
LTACH and has non-complex wound care needs.  LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulation (PNS) device (64555, 
C1778). 
 
You asked the Plan to pre-approve a PNS. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested item is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.    
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this 
peripheral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a peripheral nerve stimulation (PNS) device (64555, C1778).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast surgery. 
 You asked the Plan to pre-approve the requested services. You say that you are in pain. The Plan denied your 
request. The Plan says cosmetic surgery is not a Medicare benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that reconstructive surgery is only covered under 
certain medical indications. 
 
We looked at the file and Medicare rules. The medical records show that a breast lift, mastopexy, with implants 
was requested. The records show that the services are for cosmetic purposes. Based on this information, we 
decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve breast surgery.