Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the CardioMEMS device. 
 
You asked the Plan to pre-approve implantation of the CardioMEMS device. You say that the patient meets 
criteria for this device and it is Food and Drug Administration (FDA)-approved. The Plan denied your request. 
The Plan says implantation of the CardioMEMS device is not medically necessary for the patient'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 implantation of the CardioMEMS 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the CardioMEMS device was approved by the FDA in 
2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery 
pressure in the management of patients with congestive heart failure. The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device . In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, 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 patients 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 implantation of the CardioMEMS device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of the CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve 20 additional routine transportation trips. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you have used all of your trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to approve 20 additional routine transportation trips.
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 you are requesting reconsideration for the denial 
of an IRF admission. The Plan denied your request. The Plan says based on medical records and clinical 
information reviewed, the request for an IRF admission cannot be approved. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that the enrollee would meet criteria for admission 
to an acute inpatient rehabilitation facility. The enrollee can receive further services 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the enrollee continued stay at acute hospital until the enrollee is stable 
enough for discharge to a lower level of care has not been denied. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 72-year-old for whom coverage of LTACH services is requested. 
 
At issue is whether LTACH services for the enrollee is a covered service under Medicare rules. LTACHs are certified under Medicare as short-term acute care hospitals that have been excluded from the acute care hospital 
inpatient prospective payment system (PPS) in the Social Security Act, Section 1886(d)(1)(B)(iv) and, for 
Medicare payment purposes, are generally defined as having an average inpatient length of stay of greater than 
25 days. Services in an LTACH must be medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical care. 
The services must be able to be furnished safely and effectively only on an inpatient basis. 
 
In this case the enrollee was admitted with acute hypoxic respiratory failure in the setting of an intracranial 
hemorrhage. The record indicates that the enrollee has multiple ongoing acute medical issues and still require 
acute critical 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 the enrollee is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does 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 is a 81 year old for whom coverage of LTACH services is requested. 
 
At issue is whether LTACH services for the enrollee is a covered service under Medicare rules.  LTACHs are 
certified under Medicare as short-term acute care hospitals that have been excluded from the acute care hospital inpatient prospective payment system (PPS) in the Social Security Act, Section 1886(d)(1)(B)(iv) and, for 
Medicare payment purposes, are generally defined as having an average inpatient length of stay of greater than 
25 days.  Services in an LTACH must be medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical 
care. The services must be able to be furnished safely and effectively only on an inpatient basis. 
 
In this case the enrollee was admitted with pneumonia.  The record indicates that the enrollee has ongoing 
acute medical issues and, although is improving, but 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 the enrollee is not currently receiving 
but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary. The Plan 
denied your request. The Plan says it is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 67-year-old for whom coverage of LTACH services is requested. 
 
At issue is whether LTACH services for the enrollee is a covered service under Medicare rules.  LTACHs are 
certified under Medicare as short-term acute care hospitals that have been excluded from the acute care hospital inpatient prospective payment system (PPS) in the Social Security Act, Section 1886(d)(1)(B)(iv) and, for 
Medicare payment purposes, are generally defined as having an average inpatient length of stay of greater than 
25 days.  Services in an LTACH must be medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical 
care. The services must be able to be furnished safely and effectively only on an inpatient basis. 
 
In this case the enrollee was admitted with a stroke. 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 the enrollee is not currently receiving but that would be available at the 
LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of SNF care.
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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for LTACH services. 
 
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 an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rezum water vapor therapy (53854). 
 
You asked the Plan to pre-approve Rezum water vapor therapy. You say that please be aware that Medicare 
covers this procedure. This is an FDA approved procedure. The Plan denied your request. The Plan says the 
enrollee is a poor candidate at for surgery at this time. 
 
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 Rezum water vapor therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the medical records provided do not meet the requirements listed in the 
LCD for Medicare coverage of Rezum water vapor therapy 53854. The records do not show that the enrollee 
has been treated with medications in the past for their lower urinary tract symptoms. The records show that the 
enrollee has good health with no co-morbidities and is not taking any medication and therefore is not a poor 
candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac disease, pulmonary 
disease, etc.), or at high risk of bleeding. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rezum water vapor therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Rezum water vapor therapy (53854).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Verquvo. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. 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 Verquvo.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are an extreme fall risk and require IRF service 
to overcome mobility issues and address functional deficits. The Plan denied your request. The Plan says the 
request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that the enrollee is independent with mobility and self-care tasks. The enrollee has pain 
and uses medical equipment, but no recent functional status change specified thus does not show any clinical 
need for further home health physical or occupational therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral (64493). 
 
You asked the Plan to pre-approve the facet joint injection. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says that based on Medicare 
guidelines, the facet joint injections requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 facet joint injection. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has had physical therapy, chiropractic and a home exercise program. The 
enrollee's medications have included Lyrica, Tramadol and Diclofenac. The magnetic resonance imaging 
(MRI) shows facet joint arthropathy. The request meets all of the criteria for a facet block. The request is 
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 facet joint injection have been met. Therefore, we decided that the Plan has 
to pre-approve the injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral (64493).  
 
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.