Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee is not able to tolerate therapy three hours a day.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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 physician reviewer found that the enrollee is at a minimal assist level for standing up, moderate to maximal assist for dressing, and minimal assist for bed mobility and transfers. The enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.

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 Tresiba Flextouch U-100. 
 
You asked the Plan to pre-approve Tresiba Flextouch U-100. You say that the enrollee has a longstanding 
history of diabetes, second to pancreatic insufficiency due to recurrent pancreatitis. You say that the enrollee 
has had multiple episodes of severe hypoglycemia requiring hospitalization due to his hypoglycemia 
unawareness. You say that the enrollee is very sensitive to insulin and the use of Tresiba has decreased the 
frequency and severity of these episodes, compared to other basal insulins such as Humulin N, glargine, and 
Levemir. The Plan denied your request. The Plan says the enrollee does not have Part D coverage through 
them. 
 
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 Tresiba Flextouch U-100.  
 
Benefits for Tresiba Flextouch U-100 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehab to have any chance at improvement. 
The Plan denied your request. The Plan says you are not able to tolerate intensive rehab. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for coronary artery bypass surgery with post-operative 
complications. Your medical problems are now stable. The complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. There is not a reasonable expectation that you will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. The medical record supports a need for 
physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy 
program. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you do not require daily skilled nursing and/or daily skilled 
rehabilitation services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) 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 the enrollee has stabilized and is in need of intensive 
rehabilitation to regain her strength. The Plan denied your request. The Plan says IRF criteria are not met in this 
case. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that her functional level requires  an 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy. 
 
You asked the Plan to pre-approve knee arthroscopy. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 knee arthroscopy. 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 compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request at this time. Therefore, this request for knee arthroscopy would not 
be considered 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 knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee arthroscopy.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have a medical reason for these services and has natural supports 
available. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the requested 
services do not meet the definition of home health aide services as per Section 50.2. The enrollee has caregiver 
assist in his home and the requested 17 home health services are not reasonable and necessary to the treatment 
of the enrollee's illness or injury by the skilled professional staff or needed to maintain the enrollee's health or 
to facilitate treatment of the enrollee's illness or injury. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cochlear device implantation, with or without 
mastoidectomy (69930) and Cochlear device, includes all internal and external components (L8614). 
 
You asked the Plan to pre-approve the cochlear implant. You say that given the severity and frequency of her 
vertigo attacks as well as ipsilateral hearing loss, she is a candidate for a left labyrinthectomy. The Plan denied 
your request. The Plan says the criteria for cochlear implantation is not met. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.  
 
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 cochlear implant. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found The enrollee does not meet the requirements listed in the NCD for Medicare 
coverage. She does not have bilateral hearing loss in the moderate-to-profound range. Her test scores were not 
less than 40% in the best-aided condition. In addition, she is not enrolled in a clinical trial. Therefore she does 
not meet the requirements states. 
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of the cochlear implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cochlear device implantation, with or without mastoidectomy (69930) and 
Cochlear device, includes all internal and external components (L8614).
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is 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 patient appears to be more stable but requires additional short-term acute care 
services (less than 25 days), which can be completed in the current setting. The patient does not require 
services at the LTACH that are not already available at the current setting. There are no services at the LTACH 
that the patient requires that are not already available and covered at the current hospital setting. Therefore, this 
request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may 
be considered soon. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need a ride to dialysis until the 
end of the year. The Plan denied your request. The Plan says you have utilized the maximum number of trips 
allowed per year. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 10 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on the information provided, 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 pre-approve additional routine transportation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the IMRT services. You say that the requested treatment is medically 
reasonable and necessary. The Plan denied your request. The Plan says the type of treatment requested is not 
supported to treat the type of cancer the enrollee has, based on the way it currently appears. 
 
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 IMRT services. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has low-risk prostate cancer by PSA and Gleason score and intermediate risk 
prostate cancer by Oncotype testing was offered upfront low dose rate brachytherapy boost to be followed by 
IMRT to the prostate/pelvis.  
 
At issue is the need for IMRT after having received brachytherapy. Because of the lack of survival benefit with 
the addition of brachytherapy to IMRT, it remains somewhat controversial within the field. From the principles 
of radiation therapy section, the NCCN guidelines state that a brachytherapy boost in men with intermediate 
and high-risk prostate cancer has demonstrated an improved biochemical control, but with greater toxicity. The 
most recent NCCN guidelines (v2.2020) include, as treatment options for unfavorable intermediate risk 
prostate cancer, external beam radiotherapy + brachytherapy +/- androgen deprivation therapy for patients with 
expected survival more than 10 years. However, for favorable intermediate risk, and survival expected more 
than 10 years, the NCCN guidelines recommend external beam radiotherapy alone or brachytherapy alone. A 
patient with Gleason 6 disease and no other risk factors would not have been eligible for the ASCENDE-RT 
trial, which serves as a basis to consider combined treatment as an accepted standard. Our physician reviewer 
found that, based on expert guidelines, the requested treatment would not be in accordance with the accepted 
standards of care or be considered 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 IMRT services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 home health occupational therapy visits (G0152). 
 
You asked the Plan to pre-approve the occupational therapy visits. You say that you respectfully appeal the 
denial of occupational therapy services and believe that these are necessary for this enrollee's medical 
condition. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria 
for the requested service. 
 
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 the occupational therapy visits. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation doesn't support that the member requires skilled nursing 
services or additional skilled rehab services, beyond what has been authorized, to provide treatment that is 
medically necessary. The enrollee does not require skilled nursing or rehab services to effectively provide 
treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to 
maintain the patient's condition and/or prevent deterioration.  His function has improved and plateaued and the 
additional occupational therapy sessions that have been authorized is sufficient to teach a home exercise 
program. 
 
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 occupational therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 5 home health occupational therapy visits (G0152).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care. 
 
You asked the Plan to pre-approve home health care. You say that you have been falling frequently since you 
stopped receiving home health care. The Plan denied your request. The Plan says the coverage criteria have not 
been met. 
 
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 care. Our reviewer says 
that the requested services are not medically necessary. Our physician reviewer found the records do not show 
that skilled nursing services are required to effectively provide treatment, care, or services in order to improve 
your condition, or to establish/perform a maintenance program to prevent deterioration.  You do not have a new 
tracheostomy tube, new enteral feedings, IV antibiotics, complex wound care or other skilled nursing needs.. 
 
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 care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 still requires acute hospital level of care services and is receiving 
appropriate care at the present acute care hospital. The review has determined that the enrollee does not require 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The 
requested LTACH services are not 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. 
 
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.