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

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from September 2, 
2020. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. The Plan denied your request. The Plan 
says inpatient care 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 continued inpatient psychiatric care. 
Our reviewer says that the requested inpatient care is not medically reasonable and necessary. Our physician 
reviewer found that the enrollee was compliant with treatment while not showing any acute threats to safety. It 
did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level 
of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self 
or others but was compliant with her treatment. It did not appear that active treatment was taking place beyond 
the date in question. It did not appear that the services were reasonably expected to improve the enrollee's 
condition or for the purpose of diagnosis beyond the date in question. 
 
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 inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric care from September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid-circulating cold pad with pump for the enrollee. 
 
You asked the Plan to pre-approve the pad. You say that this is medically necessary. The Plan denied your 
request. The Plan says this could help the enrollee, but it is not covered. 
 
The Plan must follow Medicare rules. The rules say that a a fluid circulating cold pad with pump (E0218) will 
be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The requested item is statutorily not covered. Based on this 
information, we decided that Medicare rules for coverage of the pad have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a fluid-circulating cold pad with pump for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: skilled nursing 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 based on review of the medical records, the enrollee does not meet the CMS 
coverage criteria for an IRF admission based on lack of medical stability with abnormal kidney function and 
lack of nursing needs and current functional status. The medical issues require monitoring by an acute care 
physician. The documentation does not support that there is a need for an intensive therapy program with 3 
hours a day and an interdisciplinary approach to rehab care. The enrollee's rehab needs can be met in an 
alternate, less intense setting once medical stability is established. 
 
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 admission to an inpatient rehabilitation facility (IRF) 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 there is no need for 3 
hours of therapy, or close physician involvement. 
 
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 generally medically stable. There is no evidence of complex medical issues. There is no 
evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. The 
documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an 
interdisciplinary approach to rehab care. Therefore, an IRF admission 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 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 pay for home infusion therapy services provided from April 1, 2020, through May 19, 2020.You asked the Plan to pay for the home infusion therapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for home infusion therapy services provided from April 1, 2020, through May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950) and the root canal (D0330) 
provided on April 27, 2020 by an out of network provider. 
 
You asked the Plan to pay for the dental services. You say that you have always used network dentists. You say 
that the one time you go out of network you find out you need a filling and root canal. You also say that you 
feel these services should be covered. The Plan denied your request. The Plan says core build up is not listed as 
a covered service. The Plan also says that root canal is not listed as a covered service either. 
 
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 core build up and root canal are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
build up (D2950) and the root canal (D0330) provided on April 27, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve The Synclara Cough System (cough stimulating 
device (E0482)). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the device is not 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 the device. Our physician reviewer 
found coverage criteria for a cough-assist device are not met. This patient has recurrent aspiration pneumonia 
and swallowing problems related to recurrent strokes in the past. The patient has difficulty managing 
secretions. There is no evidence or expectation that a cough-assist device would be beneficial in this situation. 
The patient does not meet the coverage criteria of neuromuscular disease with impairment of diaphragm 
function. A cough-assist device 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve The Synclara Cough System (cough stimulating device (E0482)).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not have 
complex wound care or other ongoing SNF level SN need. The patient's functional level appears to be near 
baseline and does not require skilled therapy services with the specialized skill, knowledge and judgment of a 
qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. 
The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a 
"daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain. 
 
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says a PET scan is 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 scan. Our reviewer says that the 
requested PET scan is not medically reasonable and necessary. Our physician reviewer found that the 
applicable NCD states that the requested service is only covered for patients "who meet diagnostic criteria for 
both AD and FTD". In this case, the notes provided for review did not support that this requirement for 
coverage had been met. The member was not suspected of having FTD. Nor did he meet the diagnostic criteria 
for FTD. Medicare otherwise does not cover the use of PET-CT scans of the brain in the evaluation of different 
forms of dementia. 
 
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 scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approveCT scan of the lumbar spine.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere has been no failure of conservative treatment.The Plan must follow Medicare rules. Medicare rules say that CT 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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found your described left lower extremity weakness is of concern. There has been conservative therapy with medications without improvement. There are no symptoms of cauda equina syndrome. While plain x-rays have not been done, they would not be necessary without a history of trauma. The trial of 2 weeks of oral medications including steroids represents a good faith effort of conservative management.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 scan have been met.Therefore, we decided that the Planhas to pre-approveCT scan of the lumbar spine.If the Plandoes 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/orsend 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-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF 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, the enrollee does not meet the CMS coverage criteria for an IRF admission based on lack of medical and nursing needs and current functional status. There is no evidence of medical issues that require monitoring by an inpatient rehab physician three (3) times a week. The documentation does not support that there is a need for an intensivetherapy program with 3 hours a day and an interdisciplinary approach to rehab care. The enrollee has no endurance to participate in IRF level of therapies. This enrollee, does not meet the CMS coverage criteria for an IRF admission. The enrollee's rehab needs can be met in an alternate, less intense 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-approveacute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kyphoplasty to treat spinal compression fractures 
(collapse of a spine vertebrae bone). 
 
You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 the services. Our physician reviewer 
found the records show that the patient has minimal pain when wearing the brace. Kyphoplasty has been 
recently shown not to be more effective than sham treatment. It is not needed in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Kyphoplasty to treat spinal compression fractures (collapse of a spine vertebrae bone).
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 be improving, but still requires additional short term (less than 
25 days) of additional acute care services. The patient does not require services at the LTACH that are not 
already available at the current hospital. There are no services at the LTACH that the patient requires that are 
not already available and covered at the current hospital. Ongoing care at the current location appears to be 
most appropriate for the short term. 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, based on the 
improvement in the clinical course. 
 
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 LTACH services that began on October 8, 2020. 
 
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 require ongoing acute care services and not be sufficiently 
stable for discharge at this time. The patient does not require services at the LTACH that are not already 
available at the current setting. There are no services that the patient requires that are not already available and 
covered at the current setting. Therefore, this request for LTACH services will be considered not medically 
necessary at this time. Stability with nutritional and ventilator needs may be safely achieved in the current 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services that began on October 8, 2020.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the gastric bypass and repair of hiatal hernia. We decided that the 
Plan does not have to pre-approve the liver biopsy.  
 
You asked the Plan to pre-approve the surgery. You say that you would like reconsideration because these 
services are medically necessary. The Plan says that the documentation is not clear about the benefits of this 
procedure or which procedure is being offered. 
 
We decided that the Plan has to pre-approve the gastric bypass and repair of hiatal hernia.  
 
The Plan follows Medicare rules. Medicare rules say that bariatric surgery is covered for enrollees who have 
been unsuccessful with medical treatment for obesity, have a body mass index (BMI) of greater than or equal to 
35 and have at least one co-morbidity related to obesity. 
 
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 surgery. Our reviewer says that the 
member meets all criteria for bariatric surgery with a BMI that is greater than 35, presence of an obesity related 
condition and failure of conservative dietary efforts. This member has several serious obesity conditions and 
has failed dietary efforts at weight loss. This member also has a 2 cm hiatal hernia. Conversion to gastric 
bypass and repair of hiatal hernia are determined to be medically necessary for treatment of morbid obesity and 
hiatal hernia. 
 
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 gastric bypass and repair of hiatal hernia have been met. Therefore, we 
decided that the Plan has to pre-approve the gastric bypass and repair of hiatal hernia.  
 
We also decided that the Plan does not have to pre-approve the liver biopsy. 
 
The Plan follows Medicare rules. Medicare rules say that services that are not medically necessary are not 
covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the liver biopsy. Our physician 
reviewer found a liver biopsy is not standard treatment and not medically justified. 
 
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 liver biopsy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the liver biopsy. 
 
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.