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

 
We decided that the Plan does not have to pre-approve a stellate ganglion nerve block (64510). 
 
You asked the Plan to pre-approve a stellate ganglion nerve block. You say that the enrollee needs this service. 
The Plan denied your request. The Plan says the enrollee has none of the required conditions to qualify for this 
service. 
 
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 stellate ganglion nerve block. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient high-quality evidence to support this procedure in this 
clinical situation. There was no evidence that the enrollee had a clinical indication with more supportive 
literature or based on current guidelines to justify this procedure.  
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 stellate ganglion nerve block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a stellate ganglion nerve block (64510).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a conductive garment (E0731) provided on August 19, 2022. 
 
You asked the Plan to pay for the item. You say that this should be paid for. The Plan denied your request. The 
Plan says the criteria for a conductive garment is not 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 pay for the item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was given the KneeHab garment to facilitate muscle reconditioning. The garment does 
not meet the criteria of the LCD and therefore, the request is 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 the item have not been met. Therefore, we decided that the Plan does not have 
to pay for a conductive garment (E0731) provided on August 19, 2022.
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 enrollee meets the criteria for a 
medically appropriate LTACH admission. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. 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. 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 inpatient rehabilitation is physically and medically 
necessary for the enrollee to return home at their maximum level of functioning with a decreased risk for 
readmission. The Plan denied your request. The Plan says the IRF services requested 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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nail debridement, 6 visits.  
 
You asked the Plan to pre-approve the routine foot care. You say that the enrollee needs these services. The 
Plan denied your request. The Plan says routine foot care is not covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit 
unless you have diabetic foot disease or some other condition that makes professional care of your feet 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Part C Plan was correct in denying the request to pre-approve the routine foot care. Our 
reviewer says that the requested foot care is not medically necessary. Our physician reviewer found the 
provided documentation does not support a diagnosis of diabetes, peripheral vascular disease, or pedal 
neuropathy. The reviewer found that although there is a diagnosis of onychomycosis in the podiatry notes, the 
objective and subjective complaints do not include pain, or toenails that are brittle, flaking, crumbly, with subungual detritus. Therefore, the reviewer found that the requested routine foot care is not medically 
necessary. Therefore, we decided that the Plan does not have to pre-approve nail debridement, 6 visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve block using cold therapy (Iovera) 
(64640). 
 
You asked the Plan to pre-approve Iovera. You say that you need this service. The Plan denied your request. 
The Plan says the requested service 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 the nerve block with cold therapy. Our 
reviewer says that the requested Iovera procedure is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation indicates that the Iovera device is cleared by 
the Food and Drug Administration (FDA). The reviewer found that the information available about Iovera 
indicates that the safety and effectiveness of the procedure is unproven. The reviewer found that the requested Iovera procedure is considered experimental and investigational. Therefore, 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 the nerve block with cold therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve peripheral nerve block using cold therapy (Iovera) (64640).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kanjinti. 
 
You asked the Plan to pre-approve Kanjinti. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says Kanjinti is not medically necessary. 
 
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 Kanjinti. Our reviewer says that 
Kanjinti is not medically necessary. Our physician reviewer found that the enrollee has colon cancer . Kanjinti 
is being requested to be used in combination with 5-Fluorouracil (5-FU) for the treatment of colon cancer. Its is 
required that Kanjinti be used in combination with pertuzumab, lapatinib or tucatinib. The enrollee does not 
meet these requirements. Therefore, the requested use of Kanjinti is not FDA-approved for the enrollees 
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 Kanjinti have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kanjinti.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from March 10, 2022, to March 12, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that based on the documentation provided, 
you believe that this admission was appropriate. The Plan denied your request. The Plan says that inpatient care 
rather than outpatient care is required only if the beneficiary's medical condition, safety, or health would be 
significantly and directly threatened if care was provided in a less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services rendered from March 10, 2022, to March 12, 2022.  
 
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 durable medical equipment (DME), miscellaneous, 
stairway ramp (E1399). 
 
You asked the Plan to pre-approve stairway ramp. You say that you need a temporary rental of a wheelchair 
access ramp to your home after you suffered a bimalleolar (both bones) complete ankle fracture which has left 
you unable to bear any weight. The Plan denied your request. The Plan says the request is not medically 
necessary because the item is useful in the absence of disease, it would be used outside of the home, and it is 
not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve durable medical equipment (DME), miscellaneous, stairway 
ramp (E1399).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was admitted for sacroiliitis and surgical removal of a spinal cord 
stimulator. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 
does 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 this enrollee 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the procedure is currently approved as an ambulatory procedure. There 
is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight 
stay.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care is met in this 
case. Our physician reviewer found the enrollee has a diagnosis of left shoulder pain from severe glenohumeral 
osteoarthritis. The enrollee is experiencing pain in her left shoulder, affecting ADL's. Imaging and clinical 
exam support glenohumeral osteoarthritis. She has tried and failed conservative measures. The enrollee is 
undergoing a planned elective left shoulder surgery. She is medically stable with a past medical history of 
asthma, insomnia, CHF. The planned procedure listed under CPT codes 23472 is not listed on the CMS 
Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The 
review indicates that the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve HBO therapy. You say that this provider is cheaper for the enrollee and 
insurance company. The Plan denied your request. The Plan says this provider is out-of-network with the Plan 
and the enrollee can be treated within the Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
hyperbaric oxygen (HBO) therapy to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has severe nausea caused by 
medications and back pain. 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 Ondansetron.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve absolute quantitation of myocardial blood flow 
(AQMBF), positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the AQMBF PET scan. You say that you are requesting an expedited appeal 
for the denial of an AQMBF PET scan. The Plan denied your request. The Plan says  there is not enough 
evidence showing the requested study would improve the outcome for your 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 AQMBF PET scan. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this technique is considered investigational at present given the absence of 
randomized, controlled, blinded trials to quantify clinical efficacy. The guidelines do not yet support the use of 
the technique in this role. As a result, cardiac PET scan for AQMBF would not be considered medically 
reasonable and necessary in your clinical management. 
 
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 AQMBF PET scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve absolute quantitation of myocardial blood flow (AQMBF), positron emission 
tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high frequency chest wall oscillation (HFCWO) device. 
 You asked the Plan to pre-approve HFCWO device. You say that it is potentially life-threatening if the enrollee 
does not get this vest. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that HFCWO devices are only covered if certain 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 HFCWO device. Our reviewer says that 
the enrollee does not meet criteria for use of this device. Our physician reviewer found the enrollee has been 
diagnosed with chronic obstructive pulmonary disorder (COPD), obesity hypoventilation syndrome, a chronic 
respiratory failure with hypoxia. There is no documentation of a computed tomography scan of the chest. There 
is no documentation to support a diagnosis of cystic fibrosis or bronchiectasis. There is no documentation the 
enrollee has a qualifying neuromuscular condition. The enrollee does not meet the indications for this 
procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HFCWO device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve high frequency chest wall oscillation (HFCWO) device.