Persius/hicric huggingface dataset:
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 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 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 October 9, 2020, with bacteremia and bilateral knee pain. The physical therapy (PT) note on 
October 12, 2020, states he refused PT. The IRF screen states he needs maximal to total assist for bed mobility 
and transfers. The enrollee does not require the intensity of services provided at an IRF. Specifically, the 
enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient level of care. 
 
You asked the Plan to pre-approve inpatient level of care. You say that the requested inpatient level of care is 
medically necessary. The Plan denied your request. The Plan says the requested inpatient level of care is not 
medically necessary. 
 
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 inpatient level of care. Our reviewer 
says that the requested inpatient level of care is not medically necessary. Our physician reviewer found the 
review has determined that the enrollee was stable and appropriate for observation level of care services. The 
enrollee did not require or receive any inpatient diagnostic studies or therapeutic interventions. The review has 
determined that the requested inpatient level of care starting October 9, 2020, and forward is not medically 
reasonable and necessary for the enrollee in this case. 
 
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 level of care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular stimulator. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a neurostimulation device for acupuncture is 
non-covered by Medicare. 
 
We looked at the file and Medicare rules. The item at issue is an auricular stimulator used for acupuncture. 
These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
an auricular stimulator.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on 
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
sacral osteomyelitis in the setting of chronic debility following an anoxic brain injury.  The enrollee has a 
tracheotomy and feeding tube at baseline.  The enrollee is receiving wound care and a prolonged course of 
antibiotics.  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 long term 
care 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endoscopic ultrasound to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that this physician is the best for you. The Plan 
denied your request. The Plan says that these services are available in 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 
the endoscopic ultrasound to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nerve repair with allograft. 
 
You asked the Plan to pre-approve nerve repair with allograft. You say that the requested nerve repair with 
allograft is medically necessary. The Plan denied your request. The Plan says the requested nerve repair with 
allograft is not medically necessary. 
 
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 nerve repair with allograft. Our 
reviewer says that the requested nerve repair with allograft is not medically necessary. Our physician reviewer 
found the enrollee is with a diagnosis of other specified mononeuropathies with nerve root and plexus 
disorder, unspecified. The enrollee has lichen sclerosus with pudendal nerve dysfunction. Placement of a pain 
stimulator was of no value. The requested nerve repair with allograft in this case is not medically necessary. It 
has not been shown that pudendal nerve repair with allograft is a safe and effective treatment for lichen 
sclerosus with pudendal nerve dysfunction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nerve repair with allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nerve repair with allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation 
treatment; planning. 
 
You asked the Plan to pre-approve therapeutic repetitive transcranial magnetic stimulation treatment; planning. 
You say that the requested therapeutic repetitive transcranial magnetic stimulation treatment; planning is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested therapeutic repetitive transcranial magnetic stimulation treatment; planning. 
 
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 therapeutic repetitive transcranial 
magnetic stimulation treatment; planning. Our reviewer says that the enrollee does not meet criteria for the 
requested therapeutic repetitive transcranial magnetic stimulation treatment; planning. Our physician reviewer 
found based on the information provided, this enrollee does not meet the clinical criteria for the use of TMS 
therapy utilizing LCD L33398 as he has tried two antidepressant medications from the same class with no 
augmentation therapy. Utilizing the information from this enrollee, this enrollee does not meet the LCD 
requirement for Transcranial Magnetic Stimulation (TMS) in the treatment of Major Depressive Disorder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic repetitive transcranial magnetic stimulation treatment; planning 
have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic repetitive 
transcranial magnetic stimulation treatment; planning.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to approve additional routine transports. 
 
You asked the Plan to approve these services. You say that you need transportation to appointments. The Plan 
denied your request. The Plan says you have exhausted the 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 60 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. Therefore, we 
decided that the Plan does not have to approve additional routine transports.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gazyva, Bendeka, ondansetron, dexamethasone, 
famotidine and diphenhydramine regimen. 
 
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 Original Medicare covers the cost of clinical trials. 
 
The Plan must follow Medicare rules. the rules say that Original Medicare is responsible for the costs 
associated with clinical trials. 
 
We looked at the file and Medicare rules. The file shows that the services at issue are part of a clinical trial. 
Original Medicare is responsible for the approval of these services. Therefore, we decided that the Plan does 
not have to pre-approve Gazyva, Bendeka, ondansetron, dexamethasone, famotidine and diphenhydramine 
regimen.
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 require additional therapy. The Plan denied your 
request. The Plan says that your medical and therapy needs can be met at skilled nursing facility. 
 
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. You 
are generally medically stable after recent hospitalization with no evidence of medical or nursing needs for an 
IRF and your current functional status does not require IRF level of therapies. There is no evidence of medical 
issues that require monitoring by an inpatient rehab physician three times a week. The documentation does not 
support that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary 
approach to rehab care. At supervision to min assist for all mobility, you do not need IRF level of therapies and 
you have no medical complexity. Your rehab needs can be safely and effectively met in an alternate, less 
intense setting such as in-home with services. Our physician reviewer found that your 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine laboratory services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON routine laboratory services. You say that the in network lab is 30-
40 miles from your home and the out of network lab is only 6 miles away. You say that you hope to have some 
convenience to reduce your suffering from Gout. The Plan denied your request. The Plan says the criteria for 
coverage of out of network care have 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 
routine laboratory services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve decompression and fusion of spinal levels L1-L3 and 
T10 pelvis fusion. 
 
You asked the Plan to pre-approve the requested levels of spinal fusion. You say that you believe that the 
doctor needs to do all these levels at once since otherwise you would have to return for more surgeries and this 
will help you have a faster recovery. The Plan denied your request. The Plan says the surgery as requested is 
not supported in this case. However, fusion of L3-S1 has been approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested levels of spinal fusion. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documented instability or failure of fusion. Criteria for 
multilevel spinal fusion are not met. Multilevel spinal fusion has poor success in relieving low back pain. It is 
not medically needed. 
 
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 levels of spinal fusion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve decompression and fusion of spinal levels L1-L3 and T10 pelvis 
fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 enrollee has chronic obstructive 
pulmonary disease (COPD) and obstructive sleep apnea (OSA) and has reportedly been on continuous positive 
airway pressure (CPAP) at night. The total bicarbonate is elevated suggesting possible carbon dioxide 
retention, but this is not documented with an arterial blood gas done in a stable state. Bilevel positive airway 
pressure (BiPAP) has not been tried and failed. The settings ordered for the ventilator can be provided by 
certain BiPAP devices. Medicare does not pay for a ventilator when used as BiPAP. A home ventilator is not 
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 home ventilator.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on 
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) 
following surgery for ischemic bowel.  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 long term care 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pain management injection. 
 
You asked the Plan to pre-approve a pain management injection. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says there is no physician order for the service 
you are requesting at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that there is no physician order for a pain management 
injection at this time. Therefore, we decided that the Plan does not have to pre-approve a pain management 
injection.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 enrollee has unspecified iron 
deficiency anemia. He has chronic kidney disease, diabetes, hypertension, and prostate cancer. He has not tried 
and failed the Plan's required drug of Retacrit. The records do not support that the required drug would be 
contraindicated or less effective; therefore, Aranesp is 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 Aranesp.