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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. The medical record does support a need for physical and 
occupational therapy but does not support a need for or an ability to tolerate an intensive rehabilitation therapy 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq treatments. 
 
You asked the Plan to pre-approve the Tecentriq treatments. You say that this treatment should be approved as 
he is not a candidate for surgery or platinum-based chemotherapy. The Plan denied your request. The Plan says 
there is no literature support for this treatment for non-metastatic bladder cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Tecentriq treatments. Our reviewer 
says that the requested drug treatment is not considered reasonable and necessary. Our physician reviewer 
found This review relates to a request for Tecentriq to treat an 80-year-old man with high grade bladder cancer 
that invades the lamina propria.  He has had transurethral resection.  There is no information submitted to 
indicate he has nodal or distant metastases. The pathology indicates the cancer is T1. 
 
Tecentriq is not FDA approved for localized bladder cancer. The requested use is not supported in any of the 
CMS approved compendia. This reviewer did not find any supportive citations in a PubMed search. As such, 
the use of this medication is not considered reasonable and 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 Tecentriq treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Tecentriq treatments.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered by the enrollee's 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 Xarelto for the enrollee.  
 
Benefits for this drug 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: 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 there are identifiable skilled nursing service 
needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing 
or therapy services on a daily basis. This beneficiary 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 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 computed tomography (CT) scan of the abdomen and 
pelvis (74177). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. 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. 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 a CT scan of the abdomen and pelvis. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found interestingly the 
endovaginal (EV) pelvic ultrasound while dated June 27, 2020 was dictated and signed 2 months later on 
August 27, 2020. The CT of the abdomen was dated and interpreted July 17, 2020 which obviously means the 
CT would have been available to the interpreting radiologist at the time the ultrasound, while done 2 months 
earlier, would have been available for comparison. Such a comparison however was not done. Colonoscopy has 
also not been done. There is no justification apparent for a repeat CT scan. If resolution of the ultrasound cystic 
structures is desired a repeat EV pelvic ultrasound would be sufficient. 
 
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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis 
(74177).
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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, skin and oxygen care, and daily therapy can be provided at a SNF. In this case, the 
enrollee is mostly moderate assist for functional transfers and activities of daily living (ADL's) 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 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 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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is 
mostly minimal/standby assist for functional transfers and activities of daily living (ADL's) 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that you are requesting routine 
transportation. The Plan denied your request. The Plan says neither Medicare nor the health plan covers routine 
transportation. The Plan states as a courtesy for members who need assistance with transportation you can 
contact Call My Advocate to help obtain transport for several areas and certain plans and their phone number is 
866-865-3851. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation.
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 the documentation provided, the health plan's denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve ferric carboxymaltose. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that ferric carboxymaltose is covered when specific 
criteria are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee is iron-deficient. Recent labs 
show levels low enough that they cannot be corrected without intravenous (IV) iron. The IV iron is reasonable 
and medically necessary and the standard of care for the enrollee 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 been met. Therefore, we decided that the Plan has to pre-
approve ferric carboxymaltose.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient in this case appears to be improving, but still requires additional acute 
care services for weaning attempts and other services. However, the documentation does not suggest that the 
patient is likely to warrant acute care services beyond 24 additional days. The patient does not require services 
at the LTACH that are not already available 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. Therefore, this request for 
LTACH services will be considered not medically necessary at this time. Continued services at the current 
facility appears to be most appropriate and consideration for transfer can be made 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that these trips are needed for access to medical 
appointments. The Plan denied your request. The Plan says the enrollee has used up the 24 one-way trips for 
2020. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
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 the documentation provided, the health plan's denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be 
able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care 
needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: 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 you do require physical therapy and occupational therapy services but based on the 
medical records provided you do not appear stable to transfer to an intensive inpatient rehabilitation therapy 
program. There is concern that you will not be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. Further treatment in the acute 
hospital appears most appropriate based on the available records with the option to transfer to an inpatient 
rehabilitation facility or skilled nursing facility when stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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. You say that the enrollee meets Medicare rehabilitation criteria. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does require physical therapy and occupational therapy services, but based on the 
medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. 
Our physician reviewer also found that there is concern that the enrollee will not be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
Care at the skilled nursing facility level appears to be more appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.