Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care provided to the enrollee 
from October 31, 2020, to discharge. 
 
You asked the Plan to pre-approve inpatient mental health 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 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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this patient does not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 31, 
2020, forward as this patient was not shown to be a danger to themselves or others. The patient was not 
showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing 
any threats the safety. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care provided to the enrollee from October 31, 2020, 
to discharge.
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for pneumonia. Medical problems are stable. There are no identified problems that need inpatient 
medical management. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that this patient 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Capecitabine. 
 
You asked the Plan to pre-approve the Capecitabine. You say that the requested drug is medically necessary. 
The Plan denied your request. The Plan says the accepted use of this drug for your illness requires Capecitabine 
is used a single agent or in combination with Docetaxel, not with Eribulin . The Plan says that, based on 
available information, you do not meet these requirements. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the Capecitabine. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the use of Capecitabine is not 
FDA-approved for the enrollee's diagnosis when used in combination with Eribulin. It is only FDA approved 
for the enrollee's diagnosis when used as a single agent or in combination with Docetaxel. The drug 
compendias, nor clinical research, support the use of the requested drug aside from monotherapy. 
 
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 Capecitabine have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Capecitabine.
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
drainage from an enterocutaneous fistula and were treated for recurrent abdominal abscess. Medical problems 
are stable. There are no identified problems that need inpatient medical management. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports 
a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation 
therapy program. There is not a reasonable expectation that you 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: 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 needs aggressive rehab in order to get 
back to work. The Plan denied your request. The Plan says skills of a licensed therapist are not medically 
necessary for this enrollee. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Our reviewer found that the enrollee's care needs can be met at a lower level of 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown (D2740), prefabricated post and core 
(D2954), endodontic therapy (D3310), and gingivectomy or gingivoplasty (D4212). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the dental services requested are not covered under your 
supplemental dental 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, dental codes D2740, D2954, D3310, 
and D4212 are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve a dental crown (D2740), prefabricated post and core (D2954), endodontic therapy (D3310), and 
gingivectomy or gingivoplasty (D4212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction. 
 
You asked the Plan to pre-approve the extraction. You say that this is medically necessary. The Plan denied 
your request. The Plan says the plan allows for one extraction per year. 
 
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. The Plan covers one surgical 
extraction per year. 
 
We looked at the file, and Medicare rules. There is already an approval for this service on November 4, 2020. 
This service can only be provided once a year. Based on this information, we decided that the Plan's rules for 
coverage of the extraction have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a surgical extraction.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care from November 3, 2020, to 
discharge. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is necessary. The Plan 
denied your request. The Plan says the stay is not 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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided, this patient does not meet the criteria for 
treatment in an acute inpatient mental health treatment beyond the date in question of November 3, 2020, 
forward and could have been treated in a lesser restrictive setting as the patient was not showing any suicidal or 
homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or 
aggression being cooperative and compliant while not showing any acute threats to safety. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care from November 3, 2020, to discharge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gum tissue evaluation (D0180, D4381). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is 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 
gum tissue evaluation (D0180, D4381).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Positron emission tomography (PET) with concurrently acquired 
computed tomography (CT). 
 
You asked the Plan to pre-approve a PET with CT scan. 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 must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET with CT scan. Our reviewer says 
that the documentation does support that the requested PET scan is medically reasonable and necessary. Our 
physician reviewer found you are high risk for lung cancer with a mass that is very concerning for malignancy. 
PET/CT requested for better characterization of mass. Mass has not apparently been biopsied yet. The 
documentation shows that a PET/CT will give information in a low risk, non-invasive fashion that will 
contribute to your treatment and management. Therefore, you 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 a PET with CT scan have been met. Therefore, we decided that the Plan has to 
pre-approve a Positron emission tomography (PET) with concurrently acquired computed tomography (CT).  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to have a poor prognosis and still requires additional short term 
acute care services of less than 25 days until stable, which can take place at the current facility. The patient 
does not require services at the LTACH that they are not already receiving at the current facility. There are no 
services at the LTACH that are not already available and covered at the current facility. Therefore, this request 
for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care 
may be considered when more stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Insulin lispro for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a self-administered drug. 
 
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 Insulin lispro 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 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
sepsis, pneumonia and congestive heart failure. Medical problems are stable. There are no identified problems 
that need inpatient medical management. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that you 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Purewick External Catheter System identified with code 
A9270. 
 
You asked the Plan to pre-approve Purewick External Catheter System. 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 follows Medicare rules. Medicare rules say that the Purewick External Catheter System is non-
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 Purewick External Catheter System. 
Our reviewer says that the documentation does not support that the requested Purewick External Catheter 
System is medically reasonable or necessary. Our physician reviewer found you have unspecified urinary 
incontinence. The requested Purewick External Catheter System is not covered under CPT A9270. The 
requested Purewick External Catheter System does not meet criteria per the LCD. Therefore, you do not meet 
criteria for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Purewick External Catheter System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Purewick External Catheter System identified with code A9270.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pharmacogenomic testing panel.  
 
You asked the Plan to pre-approve pharmacogenomic testing. You say that this testing is medically necessary. 
The Plan denied your request. The Plan says Medicare coverage criteria are not met. The Plan states that this 
testing is for screening purposes and it s not covered by Medicare.  
 
The Plan follows Medicare rules. The rules explicitly say that screening tests are not covered. This testing is 
being requested solely for screening purposes. Medicare does not cover this test for screening purposes. 
Therefore, we decided that the Plan does not have to pre-approve a pharmacogenomic testing panel.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you need therapy. The Plan denied your 
request. The Plan says you are not a candidate for skilled physical therapy services. 
 
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 the SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF 
admission.