Persius/hicric huggingface dataset:
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 this patient appears to require additional short-term acute care services as they are 
improving, however, it is unlikely that they will require more than an additional twenty-five (25) days. The 
patient does not require services at the LTACH that are not already available and covered at the current facility. 
There are no services at the LTACH that the patient requires that are not already available and covered at the 
current facility or lower level of care services. 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 soon. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: 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 based on review of the medical records, you do not meet the CMS coverage criteria 
for an IRF admission based on lack of medical and nursing needs and current functional status. You are 
generally medically stable after sepsis from a urinary tract infection (UTI) and there is no evidence of complex 
medical issues that require monitoring by an inpatient Physical Medicine and Rehabilitation (PM&R) physician 
three times per week or acute rehab nursing care. While you may benefit from continuing physical therapy (PT) 
and occupational therapy (OT), the documentation does not support the need for an intensive therapy program 
with therapy three (3) hours per day with frequent physician oversight and an interdisciplinary approach to 
rehabilitation care. At your current functional status with no medical complexity, you do not need IRF level of 
care. You do not meet the CMS coverage criteria for an IRF admission. Your rehab needs can be met in an 
alternate, less intense setting such as in home with therapies. 
 
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 you need rehabilitation services. The Plan denied 
your request. The Plan says the request for an IRF admission does 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 the records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a lower level of care. Our reviewer found that you are mostly standby 
assist for functional transfers and activities of daily living, and a less intensive, longer duration of therapy will 
allow for measurable gains to be attained within a reasonable, and predicted period.  An IRF intensity is not 
warranted. 
 
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 requires intensive inpatient rehab with 
daily physician management. The Plan denied your request. The Plan says the enrollee does not have a medical 
complexity to support the need for a rehab physician, or complex interdisciplinary 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 is status post a closed right patellar fracture, and right knee arthrotomy. Post-operative 
management has included pain control. Hemodynamics are stable. 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. He is at minimal assist for mobility, and maximal assist for toilet use. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee is at baseline and does not need continued skilled 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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-approve Procrit. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found you recently had a Hb of 10.5 and HCT of 32.6. The enrollee is on Iron and B12. 
Erythropoiesis-stimulating agents, such as Procrit, are used for the treatment of anemia of chronic kidney 
disease and started when the hemoglobin is less than 10 and the transferrin saturation (TSAT) is greater than 25 
percent and ferritin greater than 200 ng/mL. This is to avoid the adverse effects associated with the use of these 
medications such as stroke and hypertension. Therefore, you do not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that intense therapy will help the enrollee get better. 
The Plan denied your request. The Plan says the enrollee has no daily skilled nursing or therapy service needs. 
 
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, the enrollee received oral medications, had stable vital signs, and was 
treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, 
the enrollee is at a contact guard to minimal assist level with functional mobility. She required varying assist 
with activities of daily living. She had ongoing receptive/expressive aphasia and cognitive deficits. Although 
there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy 
services on a daily basis. The enrollee does 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) admission and services.
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 skilled nursing care will not give the 
enrollee the best opportunity to regain baseline quality of life. You say that the criteria for medically 
appropriate LTACH admission is met. The Plan denied your request. The Plan says the request 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 that the enrollee does not require any services at the LTACH that are not already 
available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopic knee repair surgery (procedure code 29879) 
and arthroscopy lysis of adhesions (procedure code 29884). 
 
You asked the Plan to pre-approve knee surgery. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of authorization for these services is correct, because the records do not 
show that the enrollee's condition requires these surgical services beyond what the Plan already approved. 
 
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 knee surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Plan has already approved arthroscopy with meniscectomy (code 29881). There is no 
specific indication provided to support the medical necessity of this additional surgical service. The treatment 
plan was documented as right knee arthroscopy, medial meniscectomy. There is no evidence of a focal 
cartilage defect or arthrofibrosis on imaging, and no indication that the approved surgery would be insufficient 
to address the enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endoscopic knee repair surgery (procedure code 29879) and arthroscopy lysis of adhesions 
(procedure code 29884).
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 based on review of the medical records, you do not meet the CMS coverage criteria 
for an IRF admission based on lack of medical and nursing needs and current functional status. You are 
generally medically stable after an uncomplicated hip fracture and there is no evidence of complex medical 
issues that require monitoring by an inpatient PMR physician three times per week or acute rehab nursing care. 
While you may benefit from continuing physical therapy (PT) and occupational therapy (OT), the 
documentation does not support the need for an intensive therapy program with therapy 3 hours per day with 
frequent physician oversight and an interdisciplinary approach to rehabilitation care. At your current functional 
status with no medical complexity, you do not need IRF level of care. You do not meet the CMS coverage 
criteria for an IRF admission. Your rehab needs can be met in an alternate, less intense setting such as in an 
skilled nursing facility (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 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Truxima 1,000 mg given on day 1 and day 15 every 6 months for 
the enrollee. 
 
You asked the Plan to pre-approve Truxima. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that that this request does not meet criteria for coverage. 
 
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 Truxima. Our reviewer says that 
Truxima is medically reasonable and necessary for the enrollee. Truxima is FDA approved for the enrollee's 
diagnosis and literature supported in this case. Our physician reviewer found that the enrollee's condition meets 
criteria for coverage of Truxima. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have been met. Therefore, we decided that the Plan has to pre-approve 
Truxima 1,000 mg given on day 1 and day 15 every 6 months 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 documentation 
does not indicate the enrollee is able to tolerate 3 hours of therapy daily. 
 
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 have been on long-term IV antibiotics for lumbar spine diskitis and acute osteomyelitis. Co-morbid 
conditions include end-stage renal disease on dialysis. Hemodynamics are stable, and recent reports indicate 
you are not toxic, or febrile. 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 are debilitated and 
requires assist for all mobility and activities of daily living. You do not require treatment by multiple therapies, 
in 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says there is no 
clinical evidence of medical or rehab needs. 
 
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. 
 
The documentation shows that continued SNF services beyond September 10, 2020 were requested. 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 continued services. Our physician reviewer found 
that from a nursing perspective, you received oral medications, had stable vital signs, and your lungs were 
clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a standby 
assist to contact guard assist level with bed mobility and transfers. You require varying assist with activities of 
daily living. There are no 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of OCTAGAM (intravenous immune globulin or 
IVIG). 
 
You asked the Plan to pre-approve OCTAGAM. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of authorization for this drug is correct, because the records do not show 
that the enrollee has acute immune thrombocytopenic purpura and the requested does not meet the Plan's 
criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that IVIG infusion is only covered if all of the above 
criteria have been 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 OCTAGAM. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested IVIG. Our physician reviewer found the 
documentation submitted does not indicate that the enrollee meets all of the required coverage criteria for 
IVIG. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OCTAGAM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of OCTAGAM (intravenous immune globulin or IVIG).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Metformin. 
 
You asked the Plan to pre-approve Metformin. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by the Part B plan. 
 
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 Metformin.  
 
Benefits for Metformin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.