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 services are medically necessary for you to return 
to your prior level of function. The Plan denied your request. The Plan says you do not meet the criteria for 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483). 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation system. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a high frequency chest wall oscillation 
system. Our reviewer says that the services are not medically necessary. Our physician reviewer found a high-
frequency chest wall oscillation device is not medically necessary. There is inadequate evidence that high-
frequency chest wall oscillation is effective in right middle lobe syndrome. 
 
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 high frequency chest wall oscillation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the continuation of SNF care is medically necessary. 
The Plan denied your request. The Plan says the enrollee no longer requires skilled services on a daily inpatient 
basis and the continuation of SNF 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 clinical documentation shows the enrollee has had significant clinical and functional 
status change, thus the enrollee would be expected to require ongoing assessment/treatment by skilled nursing 
and skilled therapy. Clinical documentation shows that the enrollee's past level of function was requiring 
assistance with self-care tasks, modified independent with mobility tasks at wheelchair level currently requiring 
assistance with mobility and self-care tasks. Clinical documentation shows poor participation with skilled 
therapies and poor adherence to restrictions/guidance from therapists thus the medical necessity of ongoing 
daily skilled therapy is not supported. There are no specified daily skilled nursing needs thus daily skilled 
services are not supported. As a practical matter, clinical documentation does not support the medical necessity 
of continued daily skilled services on an inpatient basis in a skilled nursing facility. 
 
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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is needed for lung cancer. The Plan denied 
your request. The Plan says the records do not show that there is sufficient evidence in the current peer 
reviewed literature to show that this is a widely used or generally accepted treatment for this type of cancer. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that routine use of proton therapy for non small cell lung cancer is not a standard of care and could 
conceivably be worse given dosimetric uncertainties with proton therapy. Proton therapy is an accepted, safe 
and effective treatment modality for lung cancer. It is not clear however, that proton therapy affords any benefit over intensity modulated radiation therapy (IMRT). In summary, there is no plausible reason that proton 
therapy would be more beneficial than standard therapy for this particular enrollee. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BOTOX. 
 
You asked the Plan to pre-approve BOTOX. You say that medically necessary for treatment. The Plan denied 
your request. The Plan says this treatment is considered experimental or investigational. 
 
 
 The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. The local coverage article enumerates additional conditions and limitations of coverage for the 
requested service. 
 
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 BOTOX. Our reviewer says that there 
are not enough studies to prove this treatment works for the enrollee's condition. Our physician reviewer found 
the enrollee's condition does not meet coverage indications for this drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BOTOX have not been met. Therefore, we decided that the Plan does not have 
to pre-approve BOTOX.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excessive skin and subcutaneous tissue and abdomen 
infraumbilical panniculectomy. 
 
You asked the Plan to pre-approve excessive skin and subcutaneous tissue and abdomen infraumbilical 
panniculectomy. You say that the requested services are medically necessary. The Plan denied your request. 
The Plan says the requested 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 excessive skin and subcutaneous tissue 
and abdomen infraumbilical panniculectomy. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates 
that the enrollee has had weight loss after bariatric surgery. The record provided does not document the presence of intertrigo refractory to conservative treatment or functional impairment. The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of excessive skin and subcutaneous tissue and abdomen infraumbilical 
panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve excessive 
skin and subcutaneous tissue and abdomen infraumbilical panniculectomy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate. 
 
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 methotrexate.   
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the proper level of care that 
the enrollee needs. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
acute care and is currently unstable for transfer 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 the enrollee is receiving appropriate care in current acute care setting and unstable for 
transfer. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another.  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone debridement and biopsy procedures provided on April 
3, 2023. 
 
You asked the Plan to pay for bone debridement and biopsy procedures. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the requested 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 pay for bone debridement and biopsy procedures. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation supports soft tissue foot debridement but not bone 
debridement or biopsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone debridement and biopsy procedures have not been met. Therefore, we 
decided that the Plan does not have to pay for bone debridement and biopsy procedures provided on April 3, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that proton beam therapy is 
medically necessary and the superior treatment for prostate cancer. The Plan denied your request. The Plan 
says the request 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 proton beam radiation therapy. 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 clear evidence that proton beam therapy for prostate cancer offers any 
clinical advantage over other forms of definitive radiation therapy. To date, there is no compelling data to 
suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy (IMRT) 
or image-guided radiation therapy (IGRT). The generally accepted standard of care for prostate cancer is to 
only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 4 mg tablets 
 
You asked the Plan to pre-approve the medication. You say that this drug is medically necessary. 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 4 mg tablets  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an RFA. 
 
You asked the Plan to pre-approve an RFA. You say that the requested procedure is medically necessary to 
treat the enrollee's pain. The Plan denied your request. The Plan says the requested procedure does not meet the 
requirements for approval. 
 
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 an RFA. 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 indication in the medical literature that radiofrequency ablation is a standard 
treatment for chronic ankle pain. There is an absence of randomized blinded clinical studies examining benefit 
and long-term clinical outcomes establishing the value of this service in clinical management for this 
indication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an RFA.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve angioplasty with placement of bilateral iliac, left femoral, bilateral 
popliteal, bilateral tibial and bilateral peroneal vascular stents for claudication (37220, 37221, 37226, 37227, 
37228, 37230, 37231, 37225, 37229, 37224). 
 
You asked the Plan to pre-approve angioplasty with placement of bilateral iliac, left femoral, bilateral popliteal, 
bilateral tibial and bilateral peroneal vascular stents for claudication. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when used under certain conditions. 
 
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 angioplasty with placement of bilateral 
iliac, left femoral, bilateral popliteal, bilateral tibial and bilateral peroneal vascular stents for claudication. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the documentation meets 
coverage criteria and supports the medical necessity of the treatments in question. There is satisfactory 
evidence that the enrollee is having right greater than left leg pain that limits her ability to walk and is 
impacting her quality of life. Ankle-brachial index (ABIs) are abnormal. Pulse exam is diminished. There is 
documentation of high-grade stenosis in the right common femoral artery that could be consistent with these 
symptoms. The coverage criteria provide for treatment of lower extremity arterial occlusive lesions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of angioplasty with placement of bilateral iliac, left femoral, bilateral popliteal, 
bilateral tibial anbilateral peroneal vascular stents for claudication have been met. Therefore, we decided that 
the Plan has to pre-approve angioplasty with placement of bilateral iliac, left femoral, bilateral popliteal, 
bilateral tibial and bilateral peroneal vascular stents for claudication (37220, 37221, 37226, 37227, 37228, 
37230, 37231, 37225, 37229, 37224).  
 
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: 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 needs, wants, and is able to work with 
the physical therapist to get out of bed, strengthen their muscles and walk again after the multiple fractures that 
they have endured. The enrollee is willing to do their part and will benefit from 5 days per week of intensive 
therapy. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are 
requesting 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cyclobenzaprine. 
 
You asked the Plan to pre-approve the medication. You say that this is necessary for the enrollee. 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 cyclobenzaprine.   
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.