Persius/hicric huggingface dataset:
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 and for them to regain mobility with the goal of returning home. The Plan 
denied your request. The Plan says the enrollee is receiving the care needed in the hospital where they are now. 
 
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 has acute medical issues and still requires acute 
care services. 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH level of care is the only 
option for a safe discharge due to the need for hourly nursing, daily physician management by multiple 
specialties, telemetry, nutrition management, wound management, daily laboratory work, and physical, 
occupational, and speech therapies. The Plan denied your request. The Plan says the records do not show that it 
is medically necessary for the enrollee to be in an LTACH in place of an acute care hospital.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that while the enrollee does require services which are available at the LTACH, these services are available to the enrollee at the acute care hospital where they are currently receiving care. The Plan 
is covering this care. The services are medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and can only be furnished safely and effectively only on an inpatient basis. However, 
these services are currently available and being provided at the acute care hospital where they are currently 
admitted. There is no evidence that the LTACH would provide additional services that are not available to the 
enrollee at the acute care hospital. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869, C1821). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria for reasonable and necessary are not met as this device has not 
been shown to be safe and effective for treatment of the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. 
 
   
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869, C1821).
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 requires constant monitoring and needs 
assistance with daily functions. The Plan denied your request. The Plan says the enrollee can reasonably be 
expected to continue their recovery at a lower level of care with good success.  
 
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 does not require treatment by multiple therapies. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging/Single-Photon Emission 
Computerized Tomography (SPECT) (78452). 
 
You asked the Plan to pre-approve a SPECT scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says records do not show that the enrollee has any new cardiac symptoms or chest pain 
or that the enrollee is unable to exercise. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging can be covered 
when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SPECT scan. Our reviewer says that 
there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in 
this patients clinical management. Our physician reviewer found the enrollee has been active and without 
cardiac symptoms. There is no documentation that the ECG shows an uninterpretable pattern. There is no 
evidence provided that would support the need for radionuclide stress testing.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging/Single-Photon Emission Computerized Tomography 
(SPECT) (78452).
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 the notes do not show that the enrollee's care specifically requires the 
involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show that the enrollee has 
complex care needs that require a coordinated team approach; the notes do not show that the enrollee must 
have an intensive therapy program (3 hours a day, at least 5 days a week) 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 complexity of the enrollee's nursing, medical, and rehabilitation needs can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is 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, but the services required 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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will continue to need hourly 
nursing and respiratory care, daily physician management, telemetry, continuous pulse oximetry monitoring, 
frequent vital sign checks and physical, occupational and speech therapy. You also say that discharge to any 
lower level of care would likely result in recurrent hospitalization, morbidity, and potential mortality. The Plan 
denied your request. The Plan says the records do not show that it is medically necessary to be in an LTACH in 
place of an acute care hospital.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH 
is 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 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 home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that you need this ventilator as soon as 
possible.  The Plan denied your request. The Plan says a home ventilator is not medically necessary for this 
patient because their needs can be met with an alternative device such as a BiPAP device with average volume-
assured pressure support (AVAPS).   
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 system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that there is no 
documented history of COPD and no pulmonary test to document COPD or asses the severity. There is also no 
diagnosis of thoracic restrictive disease or neuromuscular disease. Also, there is no documentation of chronic 
carbon dioxide retention with an arterial blood gas done while stable. However, if you do have chronic carbon 
dioxide retention, you may benefit from BiPAP with AVAPS during sleep as an outpatient. Medicare does not 
cover a home ventilator when used at settings that can be provided with a 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 system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injections. 
 
You asked the Plan to pre-approve genicular nerve branch injections. You say that you need the procedure on 
your knee, so you can walk. 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 branch injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has knee pain following total knee 
arthroplasty for osteoarthritis. There is insufficient literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 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 genicular nerve branch injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. You say that the requested drug is medically necessary to treat the 
enrollee's diagnosis. The Plan denied your request. The Plan says the requested drug does not meet the 
necessary requirements for approval. 
 
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 Reblozyl. Our reviewer says that the 
requested drug does not meet the necessary criteria for approval. Our physician reviewer found that a bone 
marrow biopsy would not provide a diagnosis that would indicate a need for the requested drug. Based on the 
documentation, Reblozyl is not FDA approved for the enrollee's diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records show presence of non-vertebrogenic pathology per clinical and 
radiologic studies that could explain the source of pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found magnetic resonance imaging shows facet degenerative joint disease. The cause of 
pain is unclear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
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 is a fall risk and requires nursing care, 
physical and occupational therapy services. 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 does not require treatment by multiple therapies. 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 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. The 
Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital at this time. 
 
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 has ongoing acute medical issues and 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.