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) 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 a skilled nursing stay can be approved starting 8/18/20.
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 documentation does not support that it is reasonable to expect that the enrollee in this case will be able to fully participate in, and benefit from, the 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you fell and had back surgery, were not able to walk, 
and now they are trying to do therapy and you have no one at home that could help you to recover. The Plan 
denied your request. The Plan says you do not meet the requirements for an IRF admission. 
 
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 indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and 
other medication management, wound care, and daily therapy can be provided at a SNF. Our reviewer also 
found that you are mostly moderate/minimal assist for functional transfers and activities of daily living and 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 acute IRF admission and services.
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 the records 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, wound 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel, Ondansetron, and 
Dexamethasone. 
 
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says Original 
Medicare covers routine costs associated with clinical trials. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the requested drugs as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve Carboplatin, Paclitaxel, Ondansetron, and Dexamethasone.
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 the enrollee needs this level of care. The Plan denied 
your request. The Plan says that the member's care needs can be provided at a lesser 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. 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. Functionally given her current level, though he needs physical therapy 
(PT) and occupational therapy (OT), she does not require IRF level of therapies. The patient may benefit from 
further PT and an OT but does not require an intensive therapy program. IRF admission is not medically 
necessary based on the patient?s current functional status and lack of medical complexity. 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF 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 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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly 
minimal assist for functional transfers and activities of daily living (ADL?s) and 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve non-therapeutic continuous glucose monitor. You say that you have been using these sensors for a long time and they work well for you. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this is considered a non-therapeutic continuous glucose monitor and is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic continuous glucose monitor must meet the criteria listed above. A continuous glucose monitor which does not replace a blood glucose monitor for making diabetes treatment decisions is not covered by Medicare. We looked at the file and Medicare rules. The requested device does not replace a blood glucose monitor for decision-making and is therefore considered to be a non-therapeutic continuous glucose monitor. Based on this information, we decided that Medicare rules for coverage of non-therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
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 would like to be moved back to the hospital where they can manage your transplant concerns. The Plan denied your request. The Plan says that ongoing skilled services can be provided 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. You are medically stable with spinal stenosis with no evidence of need for supervision by physical medicine and rehab physician or need for acute rehab nursing care. Functionally given your current level, though you need physical therapy (PT) and occupational (OT), you do not require IRF level of therapies. You may benefit from further PT and an OT but do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and lack of medical complexity. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.
You asked the Plan to pre-approve a wheelchair ramp. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lotemax .5%.
You asked the Plan to pre-approve Lotemax .5%. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Lotemax .5%.
Benefits for Lotemax .5% 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 Procrit. 
 
You asked the Plan to pre-approve Procrit. The Plan denied your request. The Plan says Procrit is not covered 
for chronic anemia associated with Monoclonal gammopathy of undetermined significance (MGUS). 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Procrit. Our physician reviewer found 
that the enrollee has macrocytic anemia. The requested use of Procrit is not FDA-approved for the enrollee's 
diagnosis. The use is not supported by one of the major drug compendia, or by clinical research that appears in 
a CMS-approved medical journal. The requested use is listed as not indicated, not supported, and not 
recommended in the compendia. The documentation does not support that the requested drug is safe and 
effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings.
You asked the Plan to pre-approve the compression stockings. You say that you need to wear the garment every day. The Plan denied your request. The Plan says you do not have any underlying wounds.
The Plan must follow Medicare rules. The rules say that compression stockings are non-covered if they do not meet the statutory definition of a surgical dressing. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. Although this item may be appropriate, it does not fall into a covered benefit category. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a preventative procedure (D1999), extraction of teeth 
#4, 23, 22, and 12 (D7210), gingival irrigation (D4921), and a lower partial denture (D5212). 
 
You asked the Plan to pre-approve a preventative procedure, extraction of teeth #4, 23, 22, and 12, gingival 
irrigation, and a lower partial denture. You say that the services are necessary. The Plan denied your request. 
The Plan says the requested items are not a covered benefit. 
 
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 a 
preventative procedure (D1999), extraction of teeth #4, 23, 22, and 12 (D7210), gingival irrigation (D4921), 
and a lower partial denture (D5212).
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 is stable and suitable for transfer to an 
IRF. You say that the enrollee requires aggressive therapy and close physician monitoring. The Plan denied 
your request. The Plan says the requirements for coverage of IRF care have not been met. The Plan says that 
the enrollee can safely receive the care needed 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 the records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a skilled nursing facility (SNF) level of care.  Ongoing pain medication 
and other medication management, skin and O2 care, and daily therapy can be provided at a SNF. The enrollee 
is mostly minimal assist for functional transfers and activities of daily living. A less intensive, longer duration 
of therapy will allow for measurable gains to be attained within a reasonable and predicted period of time. 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 acute inpatient rehabilitation facility (IRF) admission and services.
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 the enrollee needs to regain strength to 
comfortably ambulate and transfer alone. The Plan denied your request. The Plan says that therapies can be 
provided at lower level of care. 
 
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 that the enrollee's condition does not 
meet Medicare criteria for SNF 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 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI of the right ankle.
You asked the Plan to pre-approve the MRI. You say that this is a medically necessary test. The Plan denied
your request. The Plan says that there is no evidence presented to support the need for this imaging.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the
requested imaging is found to be reasonable and necessary in this case. Our physician reviewer found the
enrollee has persistent pain since an ankle injury. The ankle is very complex and there is not another imaging
technique that will be helpful in confirming the working diagnosis. Ligament/tendon diagnoses are best done
with MRI. As such, this imaging is 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve
an MRI of the right ankle.
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 continued inpatient psychiatric services. 
 
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 continued services are not medically necessary. Our physician reviewer found the enrollee was admitted to 
the hospital on August 14, 2020 with Bipolar-type schizoaffective disorder. Based on the submitted records, it 
is not expected that she will improve in a reasonable period of time, as she is not showing dangerousness to 
herself or others. She has no delusions or auditory or visual hallucinations. She is not showing any aggressive 
behaviors or acute threats to safety. It does not appear that active treatment is taking place. The continued 
inpatient 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 continued inpatient psychiatric services.