Persius/hicric huggingface dataset:
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. You say that you are still in need of critical medical 
care. The Plan denied your request. The Plan says you are covered for up to 100 days each benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from June 26, 2020 to October 
8, 2020. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve preparation for an occlusal orthotic device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is not being treated for a 
dental condition. The Plan denied your request. The Plan says the item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that oral appliances are only covered under certain 
medical indications.  
 
We looked at the file and Medicare rules. Oral occlusal appliances used to treat temporomandibular joint (TMJ) 
disorders are considered to be dental devices and will be denied as non-covered. Based on this information, we 
decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve preparation for an occlusal orthotic device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
you live alone and require therapy services. The Plan denied your request. The Plan says your care needs can 
be met at a lower level with home supervision and home health 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness 
of intensity of service criteria for an inpatient basis in a skilled nursing 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF admission.
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 you need to be moved to the next level 
of care. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found that you were 
admitted to the hospital on September 22, 2020 for ongoing treatment for possible discitis after several spinal 
surgeries. You underwent lumbar spinal surgery. There is no evidence that you require services that are not 
currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of 
care, there is no advantage in transferring you to the LTACH.  You can remain at the current ACH until such 
time no acute services are required. 
 
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: 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 wound care is needed, and he is not stable on 
stairs. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or 
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 physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and had 
dressings to his left foot. There are no identifiable skilled nursing service needs. Regarding rehab services, the 
enrollee is at a supervision to independent level with functional mobility. There are no identifiable skilled 
therapy service needs. He 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: 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 no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing 
or therapy services on a daily basis. This 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient care. The Plan denied your request. The Plan says the enrollee 
does not have comorbidities that would justify an inpatient admission for the IV antibiotic administration prior 
to surgery. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient care. Our physician reviewer 
found that the medical records do not document any comorbidities that would justify an inpatient admission for 
the IV antibiotic administration prior to surgery. The preoperative IV antibiotic administration can be provided 
without an inpatient stay. The records do not show that the enrollee requires special treatment prior to the 
approved surgery. The records do not show that an inpatient admission prior to surgery is 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 inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve acute inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood measure monitor. 
 
You asked the Plan to pre-approve a blood measure monitor. You say that you need a replacement. The Plan 
denied your request. The Plan says that this is not covered by the Plan or Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a blood measure monitor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 physical therapy visits (97110). 
 
You asked the Plan to pre-approve 20 physical therapy visits. 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 Medicare pays for medically necessary outpatient 
therapy. 
 
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 20 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as 
specific and effective therapy for your condition. You have had extensive therapy for this condition and it does 
not appear that you require the unique skills of a professional therapist to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision 
of a therapist. You have been instructed in an independent exercise program and should be able to safely and 
effectively transition to a home exercise program (HEP) with the already authorized therapy. The ongoing 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
 
 
deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 20 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 20 physical therapy visits (97110).
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 Medicare coverage 
criteria for an IRF admission. You are generally medically stable with Debility at home with decline in 
function from a recent surgery for small bowel obstruction (SBO). There is no evidence of medical or nursing 
needs for an IRF. You need physical therapy (PT) and occupational therapy (OT) but not in an IRF. 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 intensive therapy program with 3 hours a day and an 
interdisciplinary approach to rehab care. The IRF admission is not medically necessary and does not meet the 
Medicare coverage criteria due to lack of medical complexity. Your rehab needs can be safely and effectively 
met in an alternate, less intense setting such as in a skilled nursing facility (SNF) or in-home with 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 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: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve IMRT services. We decided that the Plan does not have to pre-
approve .  
 
You asked the Plan to pre-approve IMRT services. You say that the enrollee is near completion of stereotactic 
body radiation therapy. The Plan says that the treatment is not recommended for the enrollee's cancer. 
 
We decided that the Plan has to pre-approve IMRT services.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for IMRT services. Our physician reviewer found that 
that the enrollee has oligometastatic Stage IV disease, and would have had Stage III non-small cell lung cancer 
(NSCLC) without distant metastases due to mediastinal nodal involvement. From the most recent NCCN 
guidelines (v8.2020), for non-small cell lung cancer, IMRT are considered appropriate when needed to deliver 
curative radiation therapy safely, i.e. adequate tumor doses while respecting normal tissue dose constraints. The 
guidelines recommend using IMRT when treating Stage III NSCLC. As the thoracic radiotherapy would be 
similar to that used for Stage III NSCLC, IMRT would be appropriate and furnished in accordance with 
accepted standards. Therefore, we decided that the Plan has to pre-approve IMRT services.  
 
We also decided that the Plan does not have to pre-approve 33 fractions of IMRT. 
 
Our physician reviewer found that for those with Stage III NSCLC, there was no advantage to escalating the 
dose beyond 60 Gy in 30 fractions with respect to survival outcomes, and those treated to higher doses fared 
worse. In the aforementioned studies of consolidative radiotherapy, 5 or 15 fractions of radiotherapy were used. 
For this enrollee, there is no rationale provided for the need of more than 15 fractions.  
 
 
In fact, 33 fractions would be outside the standard of care. With no benefit in Stage III patients to treating with 
greater than 30 fractions, doing so in Stage IV patients is even less likely to be of benefit, and possibly could 
cause harm.  Also, prolonging the thoracic radiotherapy in this enrollee would delay systemic therapy, which is 
the standard treatment. With no rationale for why 33 fractions was requested, treating with more fractions 
without a plausible rationale for why is not standard is not considered medically necessary. Therefore, we 
decided that the Plan does not have to pre-approve33 fractions of IMRT.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional home health physical therapy visits. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 8 additional home health physical 
therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or 
services in order to improve your level of function, or to establish/perform a maintenance program to maintain 
your level of function and/or prevent deterioration. You are at a high functional level, have been trained and are 
competent in a home exercise program. You do not require ongoing skilled therapy services beyond the 
authorized dates of service. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional home health physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 8 additional home health physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939). 
 
You asked the Plan to pre-approve bone marrow aspiration for bone grafting. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria has not been met. 
 
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 bone marrow aspiration for bone 
grafting. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use in 
spine fusion surgery. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration for bone grafting have not been met. Therefore, we 
decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939).
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 additional routine transportation trips. You say that the enrollee struggles to 
find transportation to their cancer treatment appointments. The Plan denied your request. The Plan says the 
enrollee exhausted their benefit. 
 
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 thirty-six (36) one-way 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. The 37th trip and 
beyond is not a covered benefit. 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation provided 
supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of 
LTACH care have not been met. The Plan says that the services needed could be provided in another 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and requires additional short term acute care 
services, but is not likely to require more than 25 days. The enrollee does not require services at the LTACH 
that are not already being provided in the current setting. There are no services at the LTACH that are not 
already available at the current setting. Ongoing acute care services at the current hospital appears to be 
appropriate and 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 long term acute care hospital (LTACH) services.