Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a spinous process spacer. 
 
You asked the Plan to pre-approve a spinous process spacer. The Plan denied your request. The Plan says this 
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 a spinous process spacer. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this device remains experimental and more research is 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 a spinous process spacer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of a spinous process spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns and office visit for observation provided 
from February 5, 2020 to February 24, 2020. 
 
You asked the Plan to pay for the crowns and office visit. You say that you thought these services would be 
covered medically because it was due to a medical issue, and not a dental problem. The Plan denied your 
request. The Plan says these services were rendered by an OON provider. The Plan also says that your plan 
does not allow for OON services.
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the two 
crowns and office visit for observation provided from February 5, 2020 to February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says IRF admission 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 that the enrollee was medically stable with no evidence of need for supervision by 
PMR Physician or need for acute rehab nursing care. Though the enrollee requires physical therapy (PT) and 
occupational therapy (OT), she does not require IRF level therapies. The enrollee 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 enrollee's current functional status and lack of medical complexity. 
 
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 battery for a push-rim activated power assist device 
for a manual wheelchair. 
 
You asked the Plan to pre-approve the battery. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a push-rim activated power assist device is covered 
when the above criteria are met. 
 
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 battery. Our reviewer says that a 
push-rim activated power assist device is not medically reasonable and necessary. Our physician reviewer 
found that this is a convenience item and not needed for optimal wheelchair functioning.  A standard light 
weight or ultra lightweight wheelchair can address the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. As the push-rim activated power assist 
device is not medically necessary in this case, the battery for the device is also considered not medically 
necessary. Based on this information, we decided that Medicare rules for coverage of the battery have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a battery for a push-rim activated power 
assist device for a manual wheelchair.
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 enrollee is reasonably expected to participate in 3 
hours of rehab therapy per day, 5 days a week, so that he may return back home. The Plan denied your request. 
The Plan says the IRF 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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also found that 
there is not a reasonable expectation that this enrollee 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 acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided 
December 5, 2019 to January 3, 2020. 
 
You asked the Plan to pay for the SNF services. You say that  The Plan denied your request. The Plan says the 
Medicare criteria for continued SNF level of coverage were 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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis and 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided December 5, 2019 to January 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary, as the enrollee is not a 
candidate for heart transplant and has been recently hospitalized twice. The Plan denied your request. The Plan 
says this is considered experimental and investigational. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this circumstance therapy change based on data obtained from a CardioMEMS device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.  
Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. The device should still be considered 
experimental and investigational. 
 
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 the CardioMEMS device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ZIOPTAN eye drops for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee needs this for treatment of glaucoma. 
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 ZIOPTAN eye drops for the 
enrollee.  
 
Benefits for this drug 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission 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 the documentation does not support that you require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. There are no services available 
at the LTACH that you require that are not available at the health care setting being offered by the health plan. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sixty (60) routine transportation trips. 
 
You asked the Plan to pre-approve sixty (60) routine transportation trips. You say that you cannot drive 
yourself. The Plan denied your request. The Plan says that your request is not covered. 
 
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) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan does not have to approve routine transportation above the benefit maximum for coverage of forty-
eight routine transportation trips. Therefore, we decided that the Plan does not have to pre-approve sixty (60) 
routine transportation trips.
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 needs to be seen daily by a 
doctor, and 24-hour nursing care. 
The Plan denied your request. The Plan says the enrollee's current needs are being met in the acute setting. 
 
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 physician 
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a 
fall resulting in a femur facture. 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. 
 
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve varicose vein surgery. 
 
You asked the Plan to pre-approve varicose vein surgery. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says that the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that varicose vein surgery is covered for certain 
indications. 
 
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 varicose vein surgery. Our reviewer 
says that the documentation supports that the requested varicose vein surgery is medically reasonable and 
necessary. Our physician reviewer found the documentation of ulceration and recurrent bleeding negates the 
requirement for a specific body mass index. There is satisfactory documentation of failure of conservative 
therapy and satisfactory documentation of adequate arterial perfusion. Absence of DVT and presence of severe 
reflux in the veins to be treated is also documented. Therefore, the enrollee meets criteria for the requested 
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 varicose vein surgery have been met. Therefore, we decided that the Plan has to 
pre-approve varicose vein surgery.  
 
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: Favorable

We decided that the Plan has to provide coverage for inpatient hospital care from February 17, 2020 through 
February 18, 2020. 
 
You asked the Plan to provide coverage for inpatient hospital care. You say that the stay was medically 
necessary. The Plan denied your request. The Plan says that the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. It appears that the plan's contracted delegate was provided the records for this 
admission and has failed to forward them to support the decision to deny based on no medical necessity. 
Therefore, we decided that the Plan has to provide coverage for inpatient hospital care from February 17, 2020 
through February 18, 2020.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic resonance cholangiopancreatography 
(MRCP). 
 
You asked the Plan to pre-approve MRCP. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested services are 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 MRCP. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have been incidentally diagnosed adrenal nodules by CT scan in 2018. You had an MRI 
which confirmed lipid rich adrenal nodules in December 2019. Hormonal workup was planned with dex 
suppression. There does not appear to be any biliary or liver pathology that is being evaluated with MRI so 
MRCP is not needed. Therefore, you do not meet criteria for the requested MRCP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRCP have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Magnetic resonance cholangiopancreatography (MRCP).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you will not be able to shower without the 
chair after surgery. The Plan denied your request. The Plan says that this is not covered by your Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that inpatient rehab is physically and medically necessary 
in order to return to home safely after hospitalization. The Plan denied your request. The Plan says the services 
do not meet the requirements for approval. 
 
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 that medication management, wound care, and daily therapy can be provided at a 
skilled nursing facility. 
 
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 an 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. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, 
the enrollee does not meet criteria for the requested 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.