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 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 for IRF admission 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The 
documentation does not support that the enrollee's functional status and activity tolerance requires an intensive 
rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. 
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) 
admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a darbepoetin alfa injection (J0881). 
 
You asked the Plan to pre-approve a darbepoetin alfa injection. 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 darbepoetin alfa injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review has determined that the requested items at issue in this case are 
not medically reasonable or 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 a darbepoetin alfa injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a darbepoetin alfa injection (J0881).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits. 
 
You asked the Plan to pre-approve the 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 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 services. 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 patient's condition. The patient has a chronic myopathy. The patient has made some 
minimal progress in therapy but the records do not indicate they require the ongoing 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 patient 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 patient'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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ten (10) additional physical therapy visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) skilled nursing visits. 
 
You asked the Plan to pre-approve the services. You say that you have a wound on your left leg that you cannot 
reach to put a bandage on or reach to take off the bandage if it were to fall off. The Plan denied your request. 
The Plan says there is no documentation that shows that skilled nursing care is required. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our physician reviewer 
found the records do not show that skilled nursing (SN) services are required to effectively provide treatment, 
care, and/or services in order to improve your condition, or to establish/perform a maintenance program to 
maintain your condition and/or prevent deterioration. You had had prior SN and were educated in disease 
management. There are no complex wounds, new enteral feedings or other SN need. Your medical conditions 
are chronic and stable. The request for 6 SN visits 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six (6) skilled nursing visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care following surgery. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient stay is necessary. 
The Plan denied your request. The Plan says they have approved the requested 63650 - Percutaneous 
implantation of neurostimulator electrode array, epidural. The Plan states the care can be provided without an 
inpatient stay. The Plan states the overnight stay can be done as outpatient and the enrollee can be observed 
post-surgery as an outpatient (23 hour stay.) The Plan states if there is clinical deterioration an inpatient stay 
can be requested. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We looked at the file, and Medicare rules. If for some reason after the surgery the enrollee's condition requires 
inpatient care the provider can admit then. Therefore, we decided that the Plan does not have to pre-approve 
inpatient hospital care following surgery.
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 the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the patient's functional status requires an intensive rehabilitation therapy program provided in an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission to the requested out-of-network 
hospital. 
 
You asked the Plan to pre-approve the inpatient admission. The Plan denied your request. The Plan says There 
is no coverage available for this out-of-network hospital. This service is available at a facility 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 hospital in this case is not a network provider with the Plan. The Plan has network hospitals 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an inpatient 
admission to the requested out-of-network hospital.
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. The Plan denied your request. The Plan says transfer 
to a LTACH is not medically necessary at this time. 
 
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 enrollee does not require services at the LTACH that are not available at the 
current setting. Our reviewer found that there are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Our physician reviewer also found that transfer to a 
lower level of care may be considered soon. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the 
case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 
pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician 
reviewer found that there are no identifiable skilled nursing service needs. The medical records provided do not 
show the enrollee requires skilled nursing or therapy services on a daily basis. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery. 
 
You asked the Plan to pre-approve spine surgery. 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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show that the enrollee is a smoker. There is no documentation of smoking cessation. 
There are no red flags for surgery now. Surgery not indicated now. The enrollee must stop smoking and more 
recent imaging studies are 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 spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiopharmaceutical localization of tumor, 
inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool 
imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis), single day 
imaging (CPT Code 78803). 
 
You asked the Plan to pre-approve the services. You say that it is recommended that the enrollee has a Datscan 
due to suspicion for Parkinson's Disease. The Plan denied your request. The Plan says the records do not show 
that the enrollee has undergone medication trials. 
 
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 services. Our physician reviewer 
found based on the documentation provided, the health plan?s denial should be upheld. The enrollee is 
suspected of having Parkinson?s disease, a condition that is diagnosed clinically and by exclusion. A request 
has been made for a DAT scan to confirm the diagnosis. This test is neither necessary nor specific to 
diagnosing Parkinson?s disease. As such, the requested test is not shown to be medically necessary or 
reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiopharmaceutical localization of tumor, inflammatory process or distribution of 
radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic 
(SPECT), single area (eg, head, neck, chest, pelvis), single day imaging (CPT Code 78803).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 PWC with multiple power options and
attachments.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied
your request. The Plan says that you do not meet criteria for coverage.
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 these services. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. The
documentation indicates you have a personal mobility deficit but there are no objective treating medical
practitioner medical progress reports indicating an objective neuromuscular examination, gait evaluation, or
evidence that there is spasticity that is significantly affecting MRADLs in the home and causing an inability for
you to effectively perform MRADLS. You reside in a long term care facility and it is not clear whether you get
assist with your MRADLS. There is no evidence that you need a Group 3 power WC with tilt and recline. It is
not evident that your spasticity with an Ashworth Score of 1 needs a Group 3 power WC for management.
There is no evidence of intermittent catheterization. The documentation does not indicate a current pressure
wound or that you require the tilt and recline for skin management. The documentation is not clear that that you
can safely operate the requested Group 3 power wheelchair with accessories. Our physician reviewer found that
your condition does not meet Medicare criteria for these items.
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 Group 3 PWC with multiple power options and attachments.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to remove excess skin from the enrollee's belly. 
 
You asked the Plan to pre-approve the service. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no mention of any complications from your pannus and therefore 
would be considered cosmetic in nature and would not meet medical necessity criteria. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The information submitted shows 
that the enrollee has a history of over 200 pounds weight loss following weight loss surgery. The notes say that 
the enrollee has excess skin in the arms and belly area. The notes do not show that this extra skin causes 
inability to walk or chronic pain or ulcers created by the belly skin fold. It does not show that the symptoms 
have been present for three (3) months and have not been able to be treated using standard medical therapy. It 
does not show photographs of the excess skin to justify the surgical procedure. Therefore, we decided that the 
Plan does not have to pre-approve surgery to remove excess skin from the enrollee's belly.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skin graft - outpatient surgery services.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the clinical information did not support the medical necessity for this service.
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 services. Our physician reviewer found based on the limited documentation provided, the health plan's denial should be upheld. While it is reported that you have had a chronic lower extremity wound, which has not responded to multiple forms of treatment, it is documented that you have received, and responded well to, one month of conventional wound therapy. Furthermore, it is noted that you are non-compliant and there is no evidence that attempts to lose weight or deal with your lymphedema have occurred. As such, the documentation does not support that the requested skin grafts are currently medically necessary or reasonable.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skin graft - outpatient surgery services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Viagra for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under 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 Viagra for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the 
case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 
pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician 
reviewer found that based on the medical records there are no identifiable skilled nursing service needs. The 
records do not show that you require skilled nursing or therapy services on a daily basis. Medicare coverage 
criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.