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

We decided that the Plan does not have to pre-approve IRF care. 
 
You asked the Plan to pre-approve IRF care. You say that you are more than capable of participating in the 
program and could benefit from the close medical monitoring as you continue your recovery from the post-
surgical complications. 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 patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. The record does support a 
need for physical and occupational therapy but there is no need for an intensive rehabilitation 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 IRF care.
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The record does support a 
need for physical and occupational therapy but there is no need for an intensive rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health physical therapy visit, for the 
enrollee. 
 
You asked the Plan to pre-approve home physical therapy. You say that the enrollee needs an additional home 
health physical therapy visit. The Plan denied your request. The Plan says the enrollee is ambulating 150 feet 
with stand by assistance and already had thirty-six (36) physical therapy visits approved back to start of care on 
March 27, 2020. 
 
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 home physical therapy. Our physician 
reviewer found the health plan's denial of ongoing home physical therapy (PT) should be upheld. The enrollee 
is ambulating more than 100 feet and mobilizing with minimal supervision. The enrollee's care needs, as a 
practical matter, can be provided at a lower level of care (ex. HEP, outpatient rehabilitation, AL, LTC). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home physical therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health physical therapy visit, for the enrollee.
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 is unable to perform daily 
functions. The Plan denied your request. The Plan says it is not clear that the enrollee will need further complex 
hospital care for more than 25 days. 
 
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 was admitted to the acute care hospital with bowel perforation. She was treated 
with surgery, IV fluids, and IV antibiotics. She required wound drains and NG tube for feeding. She has 
persistent leukocytosis and still requires draining of her wounds. The enrollee appears to still require additional 
acute care services, however, it doesn't appear likely that she will require an additional 25 or more days of 
acute care services based on current clinical notes. She does not require services at the LTACH that are not 
available at the current acute care facility. Therefore, this request for LTACH services is considered not 
medically necessary at this time, as they are unlikely to benefit from the transfer.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve Rituxan. 
 
You asked the Plan to pre-approve Rituxan. You say that the medication is necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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-approves Rituxan. Our reviewer says that the 
medication is medically necessary. Our physician reviewer found the review has determined that the 
documentation supports that the Rituxan is medically reasonable and necessary and safe and effective for the 
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 Rituxan have been met. Therefore, we decided that the Plan has to pre-approve 
Rituxan.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the request for the inpatient rehabilitation level of care exceeds his 
medical needs. 
 
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 
documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs 
requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is 
currently medically stable and the documentation does not support that he has complex medical issues that 
require acute rehab nursing care, or monitoring by an inpatient physical medicine and rehab physician three 
times per week. While the enrollee may benefit from continuing physical therapy (PT) and occupational 
therapy (OT), the documentation does not support that there is need for an intensive therapy program with 
therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 
care. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve a partial lower denture. You say that the requested item is necessary. The 
Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria has not 
been met. 
 
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 partial 
dentures once every 5 years.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a partial lower denture have not been met. The plan covers a partial lower denture once every five 
years. The record shows that you received a partial lower denture on September 5, 2018. This means that you 
are not eligible for health plan coverage of a partial lower denture at this time. Therefore, we decided that the 
Plan does not have to pre-approve a partial lower denture (D5214).
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 you were making progress. The Plan denied 
your request. The Plan says there is no need for daily skilled therapy or nursing 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 SNF services. Our physician reviewer 
found that from a nursing perspective, you received oral medications, had stable vital signs, and were treated 
for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are 
at a maximal assist to dependent level with functional mobility. You require varying assist with activities of 
daily living, but are primarily dependent. You remain with a weight-bearing restriction. Although there are 
identifiable skilled therapy service needs, you do not require skilled nursing or skilled therapy services on a 
daily basis. You do not meet severity of illness or intensity of care criteria for an inpatient basis in a SNF 
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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) 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 a continuous glucose monitor. The Plan denied your request. The Plan says 
you are not on insulin. 
 
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under 
certain medical 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 a continuous glucose monitor. Our 
physician reviewer found that you have a past medical history of type 2 diabetes mellitus. The documentation 
does not show you are being treated with insulin. Based on the rules and the medical records provided there is 
no documentation that the enrollee meets the coverage criteria for the requested device. 
 
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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the requested hospital bed. You say that you have lymphedema and need to 
have your legs elevated. The Plan denied your request. The Plan says you do not have a medical condition that 
requires a certain position that a normal bed cannot provide. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary under certain medical 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 the requested hospital bed. Our 
physician reviewer found that you have Parkinson's disease, chronic kidney disease, and morbid obesity. 
Bilateral leg edema and left leg erythema and redness with bilateral leg wounds were noted. The case file does 
not contain documentation of a condition that requires position of the body in ways not feasible in an ordinary 
bed. You do not require frequent changes in body position. There is no need for immediate changes in your 
body position. You do not require special attachments that cannot be fixed and used on an ordinary bed. 
Therefore, the requested semi-electric hospital bed 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 requested hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular genetic testing, for the enrollee. 
 
You asked the Plan to pre-approve molecular genetic testing. You say that the enrollee has metastatic prostate 
cancer and is currently being treated with Firmagon, Xgeva and Erleada. You state the enrollee's prostate 
specific antigen (PSA) level is rising and want to offer a different line of treatment. The Plan denied your 
request. The Plan says there is not enough research showing that it would be helpful. 
 
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 molecular genetic testing. Our 
physician reviewer found the criteria has not been met. Specifically, a minimum of two (2) rising prostate-
specific antigen (PSA) levels one (1) or more weeks apart, new lesions by bone scintigraphy, and/or new or 
enlarging soft tissue lesions by computed tomography (CT) or magnetic resonance imaging (MRI) has not been 
documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of molecular genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve molecular genetic testing, 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. The Plan denied your request. The Plan says the enrollee is 
medically stable and requires minimal assistance for activities. 
 
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 physician reviewer found 
that you were treated for hepatic encephalopathy and right hip fracture. Your medical problems are stable. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The record does support a need for physical and 
occupational therapy, but there is no need for an intensive rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two sacroiliac (SI) joint injections. 
 
You asked the Plan to pre-approve these services. You say that you could suffer harm if the services are not 
rendered quickly. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have low 
back pain that radiates to your right hip and right leg. You underwent a transforaminal epidural steroid 
injection (TFESI) in February of 2020 and had prior spinal surgery. There is no clinical documentation of SI 
joint disease, supported by imaging or positive testing, in the submitted records. The records do not support 
that the requested SI joint injections are reasonable or medically necessary at this time. 
 
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 two sacroiliac (SI) joint injections.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says that the 
enrollee's wound has become chronic and in need of custodial treatment. 
 
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. 
 
The original request was for 8 visits. The Plan agreed to pre-approve 3 visits. 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 5 additional home health nursing visits. Our physician reviewer found that 
the enrollee has a history of hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney 
disease, or unspecified chronic kidney disease, Non-pressure chronic ulcer of other part of right lower leg with 
unspecified severity, Polyneuropathy due to other toxic agents, and Venous insufficiency (chronic) 
(peripheral), who has a non-healing wound on her right lower leg. It is documented that the enrollee has a 
wound on her right leg measuring 3cm x 3.5 cm x 0.2cm, with moderate drainage present. The documentation 
supports that the additional home health skilled nursing visits are medically reasonable and necessary in order 
to improve the enrollee's condition, and prevent 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 home health services have been met. Therefore, we decided that the Plan has to 
pre-approve 5 additional home health skilled nursing visits.
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 the requested device. The Plan denied your request. The Plan says your 
blood sugar is not in a low or very low range. 
 
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under 
certain medical 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 the requested device. Our physician 
reviewer found that you have type 2 diabetes mellitus. Your blood sugar was stated to have been increasing 
recently while taking two oral metformin and glimepiride. You check your glucose twice daily using a 
glucometer. The provided records show that you do not test four or more times a day. You are stated to not be 
taking insulin or require frequent medication adjustments during the day. Therefore, the requested CGM will be 
considered 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.