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. You say that the enrollee would benefit from a higher level of 
rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
admission to an IRF. 
 
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 enrollee's medical status does not currently require intensive physician and 
nursing oversight only in an IRF. Our reviewer found that the enrollee may benefit from multiple therapies 
such as physical and occupational therapy, but the documentation does not support that the enrollee's functional 
status requires or can tolerate 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from therapy. The Plan 
denied your request. The Plan says the services are 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on August 23, 2020 after a fall and left hip and left elbow fractures. The medical progress note dated 
August 27, 2020 states she had no fever and was feeling well. She was out of bed with physical therapy. She 
needs minimal assistance for bed mobility, transfers, and walking 12 feet with a walker. She does not currently 
require intensive physician and nursing oversight only in an IRF. She may benefit from multiple therapies but 
does not require an intensive therapy program 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you believe the enrollee could benefit 
from the LTACH admission. The Plan denied your request. The Plan says admission to a LTACH 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 does not require services at the LTACH that are not available at the 
current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that are 
not already being provided and covered at the current facility. Our physician reviewer also found that this 
request for LTACH services will be considered not medically necessary. The enrollee may be able to transfer at 
a later date. 
 
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 the LTACH services.
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 the enrollee has not improved, and you feel IRF 
admission is needed, given the enrollee's health. The Plan denied your request. The Plan says the IRF services 
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 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 enrollee's medical status does not currently require intensive physician and 
nursing oversight only in an IRF. Our reviewer also found that the enrollee may benefit from multiple therapies 
such as physical and occupational therapy, but the documentation does not support that the enrollee's functional 
status requires or can tolerate 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that there is no other place for you to go. The Plan 
denied your request. The Plan says the admission 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 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the submitted records show that you are 
currently at an assisted living facility and tested positive for COVID. You have routine Foley catheter care and 
are medically stable. You have no skilled nursing or skilled therapy needs. You do not need skilled nursing or 
skilled therapy services on a daily basis. As a practical matter, you do not require the necessary services on an 
inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venlafaxine for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
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 Venlafaxine for the 
enrollee.  
 
Benefits for this drug 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 IRF services so you can get stronger. The 
Plan denied your request. The Plan says the IRF admission does 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 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 you do not require the intensity of services provided at an IRF.  Specifically, you 
have not shown that you require fifteen hours per week of rehabilitative services and regular physician 
evaluation.  Our reviewer also found that your care needs can 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture (D5110) and lower partial 
denture (D5212). 
 
You asked the Plan to pre-approve the upper partial denture (D5110) and lower partial denture (D5212). You 
say that the upper plate on your denture broke and the dental office couldn't repair it. You say that you cannot 
chew food properly and your health is at risk. The Plan denied your request. The Plan says your benefit has 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one complete or partial denture every five years. The Plan paid for a complete and partial denture provided on 
April 12, 2018, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve 
the upper partial denture (D5110) and lower partial denture (D5212).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart surgery to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve heart surgery. You say that this should be approved. The Plan denied your 
request. The Plan says that your records received do not indicate that you have an emergent or urgent medical 
condition, or are in need of specialized service(s) that are not available in the network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
heart surgery to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared 
for in her current condition at a skilled nursing facility or any other lower level of care. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate inpatient care, and does not require a transfer to a 
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 does not require services at the LTACH that are not available at the 
current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that are 
not already being provided and covered at the current facility. Our physician reviewer also found that this 
request for LTACH services will be considered not medically necessary. The enrollee may be able to transfer at 
a later date. 
 
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 the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services. 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan 
denied your request. The Plan says the clinical documentation does not indicate all requirements to meet 
criteria for coverage. 
 
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 
the requested PET scan is not medically necessary. Our physician reviewer found the documentation does not 
support need for a viability study based on any prior studies.  This study could be approved with documentation 
of reason why this study is indicated. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) scan services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is 
limited in participation or ability to participate in the treatment plan. 
 
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 physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and was 
treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, 
the enrollee is at a dependent to maximal assist level with bed mobility and transfers. There are no identifiable 
skilled therapy service needs. He does not require skilled nursing or therapy services on a daily basis. The 
enrollee does not meet severity of illness or intensity of service criteria for 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you have no 
skilled therapy or nursing service needs. 
 
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 physician reviewer 
found that from a nursing perspective, you received oral medications, had stable vital signs, and were 
monitored for a dry cough. There are no identifiable skilled nursing service needs. Regarding rehab services, 
you are independent with functional mobility. There are no identifiable skilled therapy service needs. You do 
not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity 
of service criteria for 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve PriMatrix dermal repair. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed many 
therapies. The Plan denied your request. The Plan says that there is inadequate evidence to support its clinical 
effectiveness. 
 
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 requested services. Our physician 
reviewer found that the service at issue in this case is medically reasonable and necessary to treat the enrollee's 
condition. At this point, the non-pressure chronic ulcer with muscle involvement needs to be treated with 
PriMatrix dermal repair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve PriMatrix dermal repair.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions (CPT D7140 and D7210), the 
removal of residual tooth roots (CPT D7250), and dental anesthesia services (CPT D9222 and D9223). 
 
You asked the Plan to pre-approve the dental extractions, the removal of residual tooth roots, and the dental 
anesthesia services. You say that you are unable to eat due to your dental pain. You say that you are losing 
weight and have not slept in days due to the pain. You say that you need medical surgery to remove tooth roots. 
The Plan denied your request. The Plan says the services in dispute are not covered benefits under your 
contract. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental extractions (CPT D7140 and D7210), the removal of residual tooth roots (CPT D7250), and dental 
anesthesia services (CPT D9222 and D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous lumbar decompression procedure. 
 
You asked the Plan to pre-approve the requested services. You say that this therapy is the best treatment option 
for the enrollee. The Plan denied your request. The Plan says the service is not covered if the enrollee is not a 
participant in a clinical trial or prospective longitudinal study. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when 
provided in a clinical study. 
 
We looked at the file and Medicare rules. The documentation provided does not indicate the enrollee is 
participating in a Medicare-approved study. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous 
lumbar decompression procedure.