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

We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee has declined in stability and a 
SNF admission is medically necessary. The Plan denied your request. The Plan says the clinical criteria for a 
SNF admission has not been 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 the SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing 
perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her lungs were clear 
and she had no shortness of breath. She was treated with droplet precautions. Regarding rehabilitation services, 
the records do not indicate that the enrollee required nor received skilled therapy. There are no identifiable 
skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not 
require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee 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 pre-approve SNF services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of a right breast implant and mastopexy. 
 
You asked the Plan to pre-approve removal of a right breast implant and mastopexy. 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 removal of a right breast implant and 
mastopexy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you underwent bilateral breast augmentation in 1987. 
Bilateral breast implant exchange was performed in 2001 due to capsule contracture. The documentation does 
not support that you have a broken or failed implant, infection, implant extrusion, siliconoma or granuloma, 
interference with diagnosis of breast cancer, or painful capsular contracture with disfigurement. Therefore, you 
do 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 removal of a right breast implant and mastopexy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve removal of a right breast implant and mastopexy.
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 requires daily physician 
management with close medical monitoring. The Plan denied your request. The Plan says the enrollee's needs 
are being met in the current 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 was admitted to the current acute care hospital with respiratory failure 
secondary to COVID-19. He was treated with steroids, convalescent plasma, remdesivir, antibiotics, and 
conservative care. He was also treated for oral candidiasis. He required intermittent BiPAP. His breathing 
status is unstable even after completing treatments, although he does not require mechanical ventilation 
currently. He also has ileus due to a small bowel obstruction. The enrollee does not require any services at the 
LTACH that are not already available at the current facility. Therefore, this request for LTACH services is not 
considered 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 physical therapy visits to be provided by an out of 
network provider. 
 
You asked the Plan to pre-approve 36 physical therapy visits. You say that there is no in-network provider that 
can provide the same level of service. You say that on sight services should be utilized for the safety of the 
enrollee and community.  The Plan denied your request. The Plan says services are available in-network. The 
Plan also says that network physical therapy sites along with Telemedicine therapy visits are available. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
36 physical therapy visits to be provided by an out of network provider.
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 has 
limited tolerance for daily intensive therapies. 
 
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 admitted for abdominal surgery. There were post-operative complications, but all medical 
problems are now stable. The complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. While the record supports a need for physical and occupational therapy, it does 
not support a need for an intensive rehabilitation therapy program. 
 
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: 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 does not 
have a need for intensive rehab with physician supervision, or a multidisciplinary team for care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that the enrollee is being treated in a skilled nursing facility after acute inpatient admission for infection of the 
left leg. All medical problems are stable. There are no complex nursing or rehabilitation needs. 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. There is not a reasonable expectation that she will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While 
the record supports a need for physical and occupational therapy, it does not support a need for an intensive 
rehabilitation therapy program. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental core buildup for tooth #6. 
 
You asked the Plan to pre-approve the core buildup. You say that you are in a lot of pain. The Plan denied your 
request. The Plan says the service is not covered. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental core 
buildup for tooth #6.
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. The Plan denied your request. The Plan says you do not need 
ongoing care from trained medical or paramedical staff. 
 
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, have stable vital signs, and tolerated an 
oral diet. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a contact 
guard to minimal assist with bed mobility and transfers. You require varying assist with activities of daily 
living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee is a fracture risk. The Plan denied your 
request. The Plan says the enrollee has not failed or has a contraindication to zoledronic acid. The enrollee does 
not have a history of osteoporosis-related fracture. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our physician reviewer found 
that the enrollee has osteoporosis and GERD. There is no history of osteoporotic fracture. It was noted that 
ibandronate and alendronate had been tried and failed. The enrollee has not tried and failed zoledronic acid. 
Zoledronic acid would not likely be any less effective or likely have adverse effects. Although she has not 
tolerated oral bisphosphonates, the IV zoledronic acid does not aggravate GERD or other GI conditions 
compared to the oral agents in the same family. There were no other evidence provided suggesting a true 
contraindication to the enrollee trying zoledronic acid. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET with CT. 
 
You asked the Plan to pre-approve a PET with CT. 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. Our reviewer says that 
the documentation does support that the requested services are medically reasonable and necessary. Our 
physician reviewer found the enrollee recently had a chest CT that showed mediastinal lymphadenopathy with 
multiple enlarged mediastinal lymph nodes and prominent right hilar lymph nodes. There was focal 
parenchymal nodularity in the medial aspect of the right lower lobe of the lung. PET CT is approved for initial 
treatment strategy when cancer is strongly suspected. Therefore, the enrollee meets criteria for the requested 
PET with CT. 
 
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 have been met. Therefore, we decided that the Plan has to pre-
approve a PET with 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires a multidisciplinary team 
approach with intense therapy to get home independently. The Plan denied your request. The Plan says the 
enrollee's rehab needs are not complex. 
 
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 the enrollee was admitted to the acute care hospital with a 2-week history of significant abdominal pain. 
Workup revealed acute diverticulitis. The hospital course has included drain care, pain management, and 
monitoring of nutritional intake. She is clinically non-toxic and now afebrile.  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. She is at maximal assist for functional transfers and activities 
of daily living. The enrollee does not  require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroxychloroquine Sulfate. 
 
You asked the Plan to pre-approve Hydroxychloroquine Sulfate. You say that this medication has really helped 
the enrollee. The Plan denied your request. The Plan says the drug to be obtained by the pharmacy benefit is 
not covered under the Part B benefit. 
 
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 Hydroxychloroquine 
Sulfate.  
 
Benefits for Hydroxychloroquine Sulfate 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get back to normal function after losing 
one of your legs. You say that you have been in the hospital for over two weeks and you need rehab to get back 
to normal life functions. The Plan denied your request. The Plan says you do not meet Medicare guidelines for 
services in an inpatient rehabilitation facility. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status 
does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from 
multiple therapies such as physical and occupational therapy but the documentation does not support that your 
functional status requires or can tolerate 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 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. The Plan denied your request. The Plan says the records do not 
support that the enrollee can tolerate 3 hours of daily intense therapy, or that the enrollee requires complex 
intensive therapy. 
 
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 the enrollee was admitted for shortness of breath, and was treated with steroids and antibiotics. All medical 
problems are now stable. There are no complex nursing or rehabilitation needs. 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. There is not a reasonable expectation that he will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the 
record supports a need for physical and occupational therapy, it does not support a need for an intensive 
rehabilitation therapy program. 
 
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not 
have a history of osteoporosis-related fracture; or has tried and failed, or has a contraindication to zoledronic 
acid. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our physician reviewer found 
that the enrollee was diagnosed with osteoporosis. There was no report of a history of an osteoporotic fracture. 
The has no intolerance, contraindication, or previously failed treatment with zoledronic acid. However, it was 
reported that she was having symptoms of dysphagia. She had and EGD 5 years prior, including an esophageal 
stretch procedure. Although zoledronic acid is a bisphosphonate medication, it is an infused drug and will not 
aggravate the enrollee's GI symptoms, or be less effective than the requested Prolia. There was no other 
contraindication to the enrollee trying zoledronic acid. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.