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's team of physicians, physical and 
occupational therapists all feel that inpatient rehabilitation is the best mode of treatment short term to help 
regain strength, balance and to learn how to prevent injury moving forward from surgery. The Plan denied your 
request. The Plan says the enrollee's condition does not meet all of the requirements for inpatient rehabilitation 
admission. The Plan says services may be provided at a lower level of care.  
 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.  
 
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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an acute IRF is medically necessary. The Plan denied 
your request. The Plan says an IRF admission 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's condition is complex and fragile, particularly in the setting of their advanced age and 
repetitive hospitalizations curtailing their normal daily mobility. Also, it is expected that the enrollee will 
participate in and benefit from services to include at minimum PT, OT, physician oversight of polypharmacy, 
cardiovascular and case manager coordination of any additional services that might be needed to ensure they 
can make a sustainable return to their current living environment. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like IRF services as you were 
independent and active before hospitalization and you wish to return to being independent as quickly as 
possible. The Plan denied your request. The Plan says you do not meet the requirements for an IRF admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found your condition is in fact sufficiently complex, and there is every reason to expect that you will participate 
in and benefit from IRF-level services to include at minimum physical therapy, occupational therapy, physician 
oversight of wound care, polypharmacy, and case manager coordination of any additional services that might 
be needed to make a sustainable return home, as well as avoid preventable readmissions to the acute hospital. It 
is unlikely that your needs could be met 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 Artacent skin substitute. 
 
You asked the Plan to pre-approve Artacent skin substitute. You say that the requested Artacent skin substitute 
is medically necessary. The Plan denied your request. The Plan says the requested Artacent skin substitute 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 Artacent skin substitute. Our reviewer 
says that the requested Artacent skin substitute is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee with a squamous cell carcinoma of the scalp and was treated 
with Mohs surgery. Following surgery, the dimensions were 5.8 x 4.5 cm on June 19, 2023. Radiation 
treatment was recommended but awaiting full healing of wound before initiating this treatment. Follow-up examinations from September 7, 2023 and September 12, 2023 did not include measurements to compare but it 
was mentioned that healing had stalled. The pictures provided reveal a significant improvement since the Mohs 
surgery. A request was made for Artacent skin substitute. However, it appears as the wound is healing with 
treatment, and without wound measurements provided in the most recent documentation to show lack of 
healing with current treatment, the Artacent skin substitute is not sufficiently supported 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 Artacent skin substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Artacent skin substitute.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio tremor stimulator device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is insufficient evidence in the 
literature that the requested Cala Trio device is effective for the enrollee's tremor. The services are not the 
standard of care and are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Cala Trio tremor stimulator device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is at high risk for hospital 
admission and potentially life-threatening exacerbations. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for approval of a ventilator. 
 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 the service is not medically necessary. Our physician reviewer found the enrollee has severe obesity and 
obstructive sleep apnea. The enrollee was recently hospitalized with mental status changes, and arterial blood 
gas (ABG) was consistent with mild chronic carbon dioxide (CO2) retention. Pulmonary function testing 
showed restrictive lung disease but an increased residual volume (RV)/total lung capacity (TLC), suggesting an 
element of air trapping. Thus, the enrollee's CO2 retention may be due to a combination of obesity 
hypoventilation syndrome and COPD. There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease. This enrollee may benefit from CPAP or BiPAP during sleep as an outpatient. The average volume-
assured pressure support (AVAPS) mode can be delivered via BiPAP, if necessary. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard  hard appliance, full arch (D9944) 
provided on July 18, 2023. 
 
You asked the Plan to pay for the occlusal guard. You say that the occlusal guard was recommended by your 
dentist as you were advised that your teeth were damaged and wearing down by grinding. You also say that 
you try to keep your teeth healthy and follow your dentists recommendations. The Plan denied your request. 
The Plan says code (D9944) for an occlusal guard is not a listed code for coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal 
guard  hard appliance, full arch (D9944) provided on July 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor.  
You asked the Plan to pre-approve a FreeStyle Libre 2 sensor. The Plan denied your request. The Plan says as 
this enrollee is not on insulin and does not have documentation of problematic hypoglycemia, a CGM is not 
covered under current Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia and has not had an in-person visit with their treating physician to 
evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on this 
information, we decided that Medicare rules for coverage of a FreeStyle Libre 2 sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), and 
comprehensive oral evaluation - new or established patient (D0150) provided on July 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went to this dental office for a fracture 
repair. You also say that you then received a letter stating they were an out-of-network provider and the 
services were not covered and you are responsible for the payment. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the panoramic radiographic image (D0330), and comprehensive oral evaluation - new or established 
patient (D0150) provided on July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nonadjunctive, nonimplanted continuous glucose 
monitor (CGM) (A4239). You asked the Plan to pre-approve a nonadjunctive CGM. You say that the enrollee cannot use half of his body 
due to a stroke. You are requesting reconsideration of the requested CGM. The Plan denied your request. The 
Plan says the records do not show that the enrollee is being treated with insulin or that he has a history of 
hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for 
coverage of a nonadjunctive CGM have not been met. Therefore, we decided that the Plan does not have to pre-
approve a nonadjunctive, nonimplanted continuous glucose monitor (CGM) (A4239).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the PET scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the imaging is needed to compare results to an 
earlier scan. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when 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 PET scan. Our reviewer says that a 
PET scan is medically necessary. Our physician reviewer found that while the patient has no biochemical 
evidence of recurrent prostate cancer there are cases in the literature where metastatic prostate cancer has 
recurred with normal prostate-specific antigen (PSA) values. The patient is high risk for metastatic disease and 
recurrence and has had a positive PET scan using a prostate-specific membrane antigen (PSMA) agent. Since 
his last scan was a year ago and was positive for lymph node metastasis it is reasonable to do a surveillance 
PET despite having a normal PSA level. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve the PET scan.  
 
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 sacroiliac (SI) joint spinal fusion. 
 
You asked the Plan to pre-approve SI joint spinal fusion. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been 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 pre-approve SI joint spinal fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no SI joint instability, fracture, or lesion. SI joint fusion for degenerative 
back pain 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 SI joint spinal fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac (SI) joint spinal fusion.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this facility treats patients with your same syndromes 
every day, and you feel it is the best place for you to be. The Plan denied your request. The Plan says based on 
Medicare guidelines, the Inpatient Rehabilitation Facility (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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission, as best summarized by the physical therapy note from October 31, 2023 and the occupational 
therapy and orthopedist notes from November 1, 2023. Your condition is in fact complex and fragile, and there 
is every reason to expect that you will participate in and benefit from IRF-level services to include at minimum 
physical and occupational therapy, physician oversight of wound care and polypharmacy, and case manager 
coordination of any additional services that might be needed to make a sustainable return, as well as avoid 
preventable readmissions to the acute hospital. It is unlikely that your needs could be met at a lower level of 
care. Therefore, the requested inpatient rehabilitation facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 an intraosseous basivertebral nerve (BVN) back 
procedure.  
 
You asked the Plan to pre-approve a BVN procedure. You say that the enrollee has vertebrogenic low back 
pain. The Plan denied your request. The Plan says this procedure has been correctly denied. 
 
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 BVN procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered 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 a BVN procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an intraosseous basivertebral nerve (BVN) back procedure.