Persius/hicric huggingface dataset:
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 enrollee meets criteria for LTACH 
care. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current 
facility. 
 
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 is currently undergoing treatment at an acute care hospital (ACH).  The 
enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires services that are not 
currently available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such 
time no acute services are required.  The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing LTC 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you are trying to taper the enrollee off of Prednisone 
within the next 3 months, and will then discontinue Prolia. You also say that this is a continuation of Prolia, 
and the enrollee needs her next dose. 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 Prolia.  
 
Benefits for 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient hospital services. 
 
You asked the Plan to pre-approve continued inpatient hospital services. You say that this is medically 
necessary. The Plan denied your request. The Plan says that there is no apparent medical necessity that would 
require a higher level of care. 
 
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 continued inpatient hospital services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. The current treatment plan is for discharge to a skilled nursing facility. There is no apparent medical 
necessity that would require a higher level of care, such as an acute inpatient stay. 
You are hemodynamically stable and requires no inpatient diagnostic studies or therapeutic interventions. Our 
physician reviewer found that your condition does not meet Medicare criteria for continued inpatient 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 continued inpatient hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient hospital services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and dental extractions from an oral 
surgeon. 
 
You asked the Plan to pre-approve the consultation and dental extractions from an oral surgeon. You say that 
tooth #31 is broken and needs to be extracted by an oral surgeon. You say that the tooth is abscessed and has 
jagged edges that are cutting your tongue and causing a lot of pain and swelling. You say that you are not able 
to eat properly because it hurts too much. The Plan denied your request. The Plan says the services being 
requested are not covered. 
 
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 coverage is limited to services 
performed by a participating general dentist. The services you are requesting coverage of are to be performed 
by an oral surgeon and not a general dentist. Therefore, we decided that the Plan does not have to pre-approve a 
consultation and dental extractions from an oral surgeon.
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 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 based on the limited documentation provided, the health plan?s denial of LTACH 
coverage should be upheld. The patient is currently undergoing treatment at an ACH for COVID-19.  The 
enrollee is not intubated/ventilated. There is no evidence that the patient requires services that are not currently 
available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in 
transferring the patient to the LTACH. The patient can remain at the current ACH until such time no acute 
services are required. The patient can then be transferred/discharged to a lower level of care for any ongoing 
LTC 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Reblozyl injections. 
 
You asked the Plan to pre-approve the Reblozyl. You say that this is needed to help with his anemia. The Plan 
denied your request. The Plan says that the enrollee has ring sideroblasts and the SF3B1 mutuation is not 
evident meaning that this drug cannot be covered. 
 
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 Reblozyl. Our reviewer says that the 
requested drug is considered reasonable and necessary in this case. Our physician reviewer found the enrollee 
has low risk myelodysplastic syndrome and has required transfusions. He has failed erythropoiesis-stimulating 
agents. This meets the FDA label and NCCN compendia citations for use of this medication. 
 
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 Reblozyl have been met. Therefore, we decided that the Plan has to pre-
approve Reblozyl injections.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is 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 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 review of available records, you do not meet criteria for coverage for an 
IRF admission. You are generally medically stable with a wound infection, treated and is back to baseline 
medically and do not need a Physical Medicine and Rehabilitation (PM&R) physician's monitoring three (3) 
times a week or needs acute rehab nursing care. You need physical therapy (PT) and occupational therapy (OT) 
for functional recovery. While you may benefit from continuing PT and OT, there is no evidence of need for an 
intensive therapy program with therapy 3 hours per day with frequent physician oversight and an 
interdisciplinary approach to rehabilitation care. Admission to IRF is not medically necessary based on lack of 
medical complexity and current functional status. Your rehab needs can be met at an alternate, low intensity 
level setting such as in a skilled nursing facility (SNF).  
 
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 long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute 
care facility. 
 
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. The patient 
appears to be improving gradually, but requires additional short term acute care services at this time. There was 
no clear indication from the documentation that the patient would likely require more than 24 additional days 
of acute care services to justify transfer. The patient does not require services at the LTACH that are not 
already available at the current facility. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan. 
 
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 Xifaxan.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. 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 a Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the spacer remains experimental at this time. More research is needed to 
show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed and cane. 
 
You asked the Plan to pre-approve a semi-electric hospital bed and cane. You say that you need these items. 
The Plan denied your request. The Plan says that the medical records do not indicate a need for these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a relevant medical records which support medical necessity for the supplies 
requested in this case. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pre-approve a semi-
electric hospital bed and cane.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Azopt 1% eye drops. 
 
You asked the Plan to pre-approve the Azopt 1% eye drops. You say that Azopt would help in controlling the 
enrollee's intraocular pressure. 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 Azopt 1% eye drops.  
 
Benefits for the Azopt 1% eye drops 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 twenty-five (25) additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have physical 
therapy appointments until the end of October. The Plan denied your request. The Plan says your benefit only 
allows forty-eight (48) trips for this service. The Plan states you currently have three (3) trips remaining and 
you will 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 Plan?s coverage rules apply in this 
case. The Plan covers a maximum of forty-eight (48) 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 49th trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve twenty-five 
(25) additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the 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 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 there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does 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 SNF 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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to 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. The patient 
appears to be improving, but requires additional short term acute care services at this time. There was no clear 
indication from the documentation that the patient would require more than 24 additional days of acute care 
services to justify transfer. The patient does not require services at the LTACH that are not already available at 
the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for LTACH 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 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT, heart, without contrast material, with quantitative 
evaluation of coronary calcium (CPT Code 75571). 
 
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our physician reviewer 
found this is not a covered service for this indication. The diagnosis does not meet the criteria for this 
test/study. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT, heart, without contrast material, with quantitative evaluation of coronary calcium 
(CPT Code 75571).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aimovig autoinjector. 
 
You asked the Plan to pre-approve the Aimovig autoinjector. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not have Part D drug 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 Aimovig autoinjector.  
 
Benefits for the Aimovig autoinjector may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.