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 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
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 therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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.  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 an IRF is the most appropriate level of care for the 
enrollee's needs. The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
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 therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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. 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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care and can be 
provided in a lower level of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper extremity prosthetic codes L6670, L6890, and 
L6708. 
 
You asked the Plan to pre-approve the requested items. You say that the enrollee needs a hook and mechanical 
hand to perform activities of daily living. The Plan denied your request. The Plan says the request does not 
meet Medicare criteria as reasonable and 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 requested items. Our physician 
reviewer found that the enrollee has a past medical history including previous left upper extremity amputation 
below the elbow. Extra accessories for an authorized replacement prosthesis are being requested. In this case, 
there is no indication from the available medical records that would support a medical necessity for extra 
(duplicate) accessories and a terminal device including a glove, which would be considered cosmetic.  
 
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 requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve upper extremity prosthetic codes L6670, L6890, and L6708.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on July 10, 2023. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary and 
should be paid. The Plan denied your request. The Plan says the enrollee did not meet the criteria for the PT 
services.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee is noted to have neck and shoulder pain. Short- and long-
term goals are provided, and the enrollee received PT with therapeutic activities. However, there is no objective 
documentation, or a physical examination provided, and this is referred to prior records, which are not 
provided.  The documentation for date of service July 10, 2023, is incomplete. Without this information it 
cannot be determined if the PT was appropriate and required the services of a skilled physical therapist. 
Therefore, the PT for July 10, 2023, 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for the physical therapy (PT) services provided on July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair (PWC), 
captain's chair, patient weight capacity 301 to 450 pounds (K0825), 22nf sealed lead acid battery (E2361 x2), 
and adjustable full-length armrests (E0973 x2). 
 
You asked the Plan to pre-approve the group 2 heavy duty PWC, the battery, and the armrests. You say that 
you are unable to leave your house and have to pay out of pocket to have people help you with chores. You 
also say that you cannot hold yourself up with a walker or cane and need a mobility device.  The Plan denied 
your request. The Plan says this request is not medically necessary. 
 
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 group 2 heavy duty PWC, the 
battery, and the armrests. Our reviewer says that the criteria for coverage have not been met. Our physician 
reviewer found the enrollee has arthritis and chronic pain but is ambulatory in the home. The enrollee does not 
require a power device to complete self-care activities in the home. 
 
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 group 2 heavy duty PWC, the battery, and the armrests have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair 
(PWC), captain's chair, patient weight capacity 301 to 450 pounds (K0825), 22nf sealed lead acid battery 
(E2361 x2), and adjustable full-length armrests (E0973 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair base (K0014). 
 
You asked the Plan to pre-approve a power wheelchair. You say that using a standard wheelchair is very tiring 
for you. You also say that you are not able to wheel yourself around. The Plan denied your request. The Plan 
says the notes show that you do not need a wheelchair in your house to take care of yourself. 
 
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 a power wheelchair. Our reviewer says that the requested power wheelchair is not medically necessary. Our physician reviewer found the provided 
records do not show that you require a powered wheelchair to manage mobility in the home. Therefore, the 
reviewer found that the requested power wheelchair 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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair base (K0014).
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 would benefit from an 
LTACH admission for continual nutritional support, physical therapy, wound care, and intravenous medication 
administration. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
admission to an LTACH. 
 
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 the requested services are medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. However, these services can be obtained at the acute care hospital where the enrollee is currently 
receiving care and transfer to an LTACH would not offer additional services not available at the enrollee at the 
current 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound screening for abdominal aortic aneurysm 
(AAA) provided on April 18, 2023. 
 
You asked the Plan to pay for the screening. The Plan denied your request. The Plan says the coverage criteria 
are not met. 
 
The Plan follows Medicare rules. Medicare rules say that screening for AAA is covered when 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 pay for the screening. Our reviewer says that the 
requested ultrasound screening for abdominal aortic aneurysm (AAA) is not medically reasonable and 
necessary. Our physician reviewer found that the enrollee is not a male, there was no mention in the 
documentation of a family history of abdominal aortic aneurysm, and the enrollee does not have risk factors for 
AAA as listed in the US Preventive Services Task Force guidelines. Therefore, the enrollee does not meet 
criteria for this ultrasound procedure based on the provided documentation and will be considered not 
medically reasonable and necessary at this time.  
 
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 screening have not been met. Therefore, we decided that the Plan does not 
have to pay for the ultrasound screening for abdominal aortic aneurysm (AAA) provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS heart failure (HF) system. 
 
You asked the Plan to pre-approve CardioMEMS. You say that you are appealing the denial, based on medical 
necessity and the scientific evidence for this technology. The Plan denied your request. The Plan says that the 
CardioMEMS device at this point should only be approved for patients enrolled in a clinical trial. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS heart failure (HF) system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on April 13, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra lightweight wheelchair (K0005). 
 
You asked the Plan to pre-approve wheelchair. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the records do not show why this is needed. 
 
The Plan follows Medicare rules. Medicare rules state that an ultra lightweight wheelchair may be 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 wheelchair. Our reviewer says that you 
do not meet criteria for this wheelchair. Our physician reviewer found the record is non-specific and does not 
indicate an ultra lightweight wheelchair is necessary to support activities of daily living in the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ultra lightweight wheelchair (K0005).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve codes E2311, E2313 and E2377. You say that the requested expandable 
controller and harness required for the expandable electronics are necessary in order for the wheelchair and the 
three medically necessary power seat functions that were approved to function. You also say that the 
wheelchair and three motors that the enrollee needs will not work without the requested electronics.  The Plan 
denied your request. The Plan says the electronic connection, expandable controller and expandable controller 
harness cannot be covered as it is 
not medically necessary to control the three approved power options through the joystick (drive interface). 
 
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 codes E2311, E2313 and E2377. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has myotonic dystrophy and impaired ambulation. Her upper extremities 
are within functional limits. The enrollee has sufficient strength and function in upper extremities to manage 
standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes E2311, E2313 and E2377 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and expandable 
controller (E2377).