Persius/hicric huggingface dataset:
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 you disagree with the denial. 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 enrollee was admitted to the hospital 
on September 13, 2020 with shortness of breath. The physical therapy note dated September 21, 2020 states she 
needs stand by assist for bed rolling and sitting up and maximal assist for lying down. She is at her functional 
baseline and has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled 
therapy on a daily basis. As a practical matter, the enrollee does 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient mental health care from September 
20, 2020 forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay was medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided it was not expected this enrollee would 
improve in a reasonable period of time beyond the dates in question as the patient was not showing any 
dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors. It was 
documented that the patient appeared improved. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question because the patient did not have any suicidal or homicidal thoughts, auditory or visual 
hallucinations or abnormal behaviors. The health plan?s denial of continued inpatient psychiatric services 
appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in 
question as noted above as the patient was not a danger to himself or others and did not have any illusions, 
auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in 
question. It did not appear that the services for the dates in question were reasonably expected or medically 
necessary to improve the patient?s condition or for the purpose of diagnosis. Our physician reviewer was 
unable to find an individualized treatment plan however the entire record is not present. It appears that the 
services were supervised and evaluated by a physician. Based upon review the records provided, this patient 
does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of September 20, 2020 forward and could have been treated in a lesser restrictive setting as the patient 
was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not 
showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to 
safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional inpatient mental health care from September 20, 2020 forward.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Rituxan (rituximab) injections to be provided at a dose of 1000mg 
in two doses every 16 weeks. 
 
You asked the Plan to pre-approve the Rituxan as prescribed. You say that the requested dose schedule is 
within the FDA approved guidelines for this medication and is clinically necessary for this particular patient. 
The Plan denied your request. The Plan says that use of this medication every 16 weeks is not allowed. This 
can only be provided every 24 weeks. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Rituxan as prescribed. Our reviewer 
says that the documentation provided does support that the requested dosage of Rituxan is medically reasonable 
and necessary for this patient. Our physician reviewer found FDA approval of this medication for the treatment 
of rheumatoid arthritis (RA) suggests physician judgement in prescribing the frequency of infusions of this 
medication as long as it is between 16 and 24 weeks. Clinically, this patient experiences arthritis symptoms 
returning around 4.5 months after infusion of Rituxan which is why the physician is prescribing it for every 4 
months. The documentation does support that the requested dosage of Rituxan is safe and effective for this 
patient. 
 
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 Rituxan as prescribed have been met. Therefore, we decided that the Plan 
has to pre-approve Rituxan (rituximab) injections to be provided at a dose of 1000mg in two doses every 16 
weeks.  
 
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 an acute setting to regain 
maximum function. The Plan denied your request. The Plan says the denial of authorization for IRF service is 
correct. 
 
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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. While the 
enrollee may benefit from multiple therapies such as physical and occupational therapy, the documentation 
does not support that the enrollee can fully participate in or has the activity tolerance for 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation for 259 additional miles. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the request exceeds the mileage limit. 
 
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 routine transportation and each one-way trip must not exceed 50 miles. 
 
We looked at your request, the records in the case file, and the rules. The file shows that you are requesting a 
routine transport trip for a total of 309 miles. Based on this information, we decided that the Plan?s rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve routine transportation for 259 additional miles.
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 need this treatment because your wife cannot 
take care of him. The Plan denied your request. The Plan says you could be treated at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that your 
functional status 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet injection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that facet injections 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found although the enrollee has a history of 
chronic neck pain and previous cervical fusion, there is no documentation of conservative care.  There is no 
documentation of physical therapy. The requested procedure is supported for predominantly axial pain that is 
not associated with radiculopathy or neurogenic claudication. The office notes indicate the enrollee has chronic 
neck pain with cervical radiculopathy. There is no documentation of a trial of physical therapy as tolerated. The 
services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a facet injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Anoro Ellipta (J3535). 
 
You asked the Plan to pre-approve Anoro Ellipta. You say that this enrollee has been receiving Anoro Ellipta 
since 2018 with no issues, and has experienced less exacerbations. The Plan denied your request. The Plan says 
this drug is not covered for the enrollee's condition by Medicare 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 Anoro Ellipta (J3535).  
 
Benefits for Anoro Ellipta 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron HCl. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 HCl.  
 
Benefits for these services 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting ten 
(10) additional trips for routine transportation. The Plan denied your request. The Plan says your benefit only 
allows thirty (30) trips for this service and you have exceeded your benefit limit. 
 
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 thirty (30) 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. The 31st trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve ten (10) 
additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve cervical radiofrequency neurotomy services. 
 
You asked the Plan to pre-approve the requested services. You say that you are in a lot of pain. The Plan denied 
your request. The Plan says that you did not  respond much to subsequent RFA treatments. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency neurotomy is only covered under 
certain medical indications. 
 
The file shows that cervical radiofrequency neurotomy at C2-3 and C3-4 was requested. 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 you were involved in motor vehicle accidents, which left you with chronic neck pain. You previously had 
diagnostic medial branch blocks (MBBs) and then radiofrequency ablation (RFA) of the cervical facets. The 
pain relief lasted more than 6 months. The request is for repeat RFA, but the Plan wants to repeat the diagnostic 
MBBs first. The diagnostic MBBs do not need to be repeated since you had extended pain relief from the prior 
RFA. Therefore, the requested procedures are 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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve cervical radiofrequency neurotomy services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the enrollee has edema in both 
lower extremities due to peripheral venous insufficiency. The Plan denied your request. The Plan says the 
services are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab). 
 
You asked the Plan to pre-approve the Prolia. You say that this medication is necessary. The Plan denied your 
request. The Plan says this medication is to be picked up from a pharmacy and cannot be covered by Medicare 
Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia (denosumab).  
 
Benefits for the Prolia 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 there are no identifiable skilled nursing service needs. The medical records do not show the 
enrollee requires skilled nursing or therapy services on a daily basis.  The enrollee's condition does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
Medicare coverage criteria are not met. 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 for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services beginning 
September 23, 2020. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the record show that you were admitted 
to the hospital on September 14, 2020 with major depressive disorder and generalized anxiety disorder. You 
have been compliant with treatment and are not showing any acute threats to your safety. You are not having 
any auditory or visual hallucinations. It does not appear that active treatment is taking place beyond the dates in 
question. The continued inpatient psychiatric services are not medically necessary to improve your condition or 
for the purpose of diagnosis. 
 
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 continued inpatient psychiatric services beginning September 23, 2020.