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

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says needs can be met at a lower level of care, such as home with home health care or 
outpatient therapy. 
 
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 records do not include MD notes, RN notes, or PT/OT/ST notes. The limited 
documentation does not show that the enrollee requires 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 admission to an inpatient rehabilitation facility (IRF).
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 the enrollee is deconditioned. 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 
with pneumonia. He has stable vital signs and continued dialysis. He received physical and occupational 
therapy in the hospital. He needs supervision to contact guard assistance with functional mobility. He needs 
varied assistance with activities of daily living. He has no skilled nursing needs. He has skilled therapy needs, 
but does not require 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 acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs could possibly be met at lower level 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. The 
patient is medically stable with no evidence of need for supervision by physical medicine and rehab Physician 
or need for acute rehab nursing care. When medically stable the enrollee can obtain therapies at home while 
waiting for surgery. Functionally given his current level, he does not require IRF level of therapies. The patient 
may benefit from further physical therapy and occupational therapy but does not require an intensive therapy 
program. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 
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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that you do not have acute symptoms that 
require 24 hour care. 
 
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 psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. it was 
not expected you would improve in a reasonable period of time for the dates in question as you did not have 
suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. You were compliant with 
treatment while not showing any aggressive or violent behavior and no acute threats to safety. It does 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 as you do not have dangerousness to self or others but are compliant with your 
treatment. Our physician reviewer found that your condition does not meet Medicare criteria for continued 
inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric hospital services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (nivolumab) injections.
You asked the Plan to pre-approve the Opdivo treatment. You say that this drug is first-line treatment for
metastatic recurrent NSCLC without no EGFR or ALK. The Plan denied your request. The Plan says there is
not sufficient evidence for this to be used as monotherapy for this condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Opdivo treatment. Our reviewer
says that the requested drug is not considered reasonable and necessary in this case. Our physician reviewer
found the enrollee has non-small cell lung cancer (NSCLC) with prior lobectomy. Her performance status is
currently too low for adjuvant chemotherapy. The requested drug is not FDA-approved as first-line
monotherapy for NSCLC. There is also no support in the major drug compendia or CMS-approved medical
journals for this drug as first-line immunotherapy.
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 Opdivo treatment have not been met. Therefore, we decided that the Plan
does not have to pre-approve Opdivo (nivolumab) injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee's family has been instructed in a home exercise program, and needs can be
effectively met with this program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and
effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition. He has
made some progress in therapy in upper extremity coordination and speed but the records indicate he had some
limitations in therapy due to cognitive deficits. He was noted to have been given a home management program
which he can perform with his spouse. He is noted to be compliant in this program. The documentation does
not support that he requires the unique skills of a professional therapist to safely and effectively provide
treatment. Services do not need to safely and effectively be performed only by a therapist, or under the
supervision of a therapist. The enrollee has had extensive therapy and was trained in a home exercise program.
The requested services are not part of a maintenance program and the specialized skill, knowledge and
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the
enrollee's current condition or to prevent or slow further deterioration.
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 occupational therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra for the enrollee. 
 
You asked the Plan to pre-approve Xiidra. You say that Xiidra is medically necessary for the enrollee. The Plan 
denied your request. The Plan says Xiidra is not covered under 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 Xiidra for the enrollee.  
 
Benefits for Xiidra 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 admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
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 tecords do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a SNF level of care. Ongoing pain medication and other medication 
management, skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of 
therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF 
intensity is not warranted. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) and occupational therapy (OT) to 
be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve PT and OT to be provided by an OON provider. You say that the requested 
provider is able to provide the services where you live thereby making it more convenient and limiting your 
risk of exposure to COVID-19. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria has not been met. 
 
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 
physical therapy (PT) and occupational therapy (OT) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stellate ganglion injections (64510). 
 
You asked the Plan to pre-approve stellate ganglion injections. You say that other treatments have not helped 
you. The Plan denied your request. The Plan says the enrollee has not tried standard treatments. 
 
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 stellate ganglion injections. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested procedure is not supported by the peer reviewed literature. The 
procedure has not shown to be effective in a randomized clinical trial. The service is not the standard of care 
and is considered experimental/investigational in nature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stellate ganglion injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve stellate ganglion injections (64510).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found 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 skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6534 that 
were issued on February 27, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that the enrollee requires the stockings for 
edema and venous insufficiency. The Plan denied your request.  
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 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 pay for the compression 
stockings identified with code A6534 that were issued on February 27, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF 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 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 based on the documentation provided, 
the medical records do not show the enrollee requires the intensity of services provided at an IRF. Specifically, 
the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular 
physician evaluation. Medicare coverage criteria for IRF admission 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup for tooth number 29 (dental code D2950). 
 
You asked the Plan to pre-approve core buildup. You say that this tooth needs a core buildup in order to hold a 
crown. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this service is not covered by the Plan. 
 
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 core 
buildup for tooth number 29 (dental code D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction of tooth (D7210), periodontal scaling 
(D4341), and deep gum/root cleaning (D4342). 
 
You asked the Plan to pre-approve dental services. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct, because the X-Rays do not show 
that the dentist would need to cut the gum near the tooth, cut the tooth into pieces, or need to also remove some 
bone to be able to remove the tooth. 
 
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. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says that 
the enrollee does not meet the criteria for the requested dental services. Our physician reviewer found the 
radiography reveals the tooth which has severe periodontal disease with extensive bone loss. The requested 
extraction is reserved for circumstances where cutting of the tooth or bone is anticipated in order to extract the 
tooth. In this instance, it would be anticipated that the tooth could be removed with elevation and forceps 
removal, which would use a different dental procedure code. The requested code is not supported by the 
documentation. The lower left quadrant has a request for scaling and root planning of four or more teeth, and 
the upper left and right quadrants for a more limited cleaning. In the lower left quadrant, tooth #21 is a 
fragment and would not be retained in the mouth. As such, the tooth would not require scaling and root 
planning leaving only three teeth in the quadrant. As the requested dental code D4341 applies to four or more 
teeth in a quadrant, and there are less than four affected teeth being retained, this dental code is not appropriate 
or medically necessary. Given the documentation submitted, the scaling and root planning requests are not 
medically necessary under the Plan's benefits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve extraction of tooth (D7210), periodontal scaling (D4341), and deep gum/root cleaning 
(D4342).