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

 
We decided that the Plan does not have to pay for total right knee replacement procedure at an inpatient level 
of care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this could be safely provided in a hospital observation setting because 
the enrollee does not have any comorbidity (additional medical conditions) conditions that would require the 
procedure to be done at an inpatient level of care setting. 
 
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of acute inpatient hospital care have not been met. The request for a total knee replacement procedure 
at an inpatient level of care is not reasonable and necessary. To have a total knee replacement procedure at an 
inpatient level of care approves the enrollee's healthcare provider should submit records showing that the 
enrollee has comorbidity (additional medical conditions) conditions that would require the procedure to be 
done at an inpatient level of care setting. The Plan did approve the total knee replacement procedure with a 
hospital observation. Therefore, we decided that the Plan does not have to pay for total right knee replacement 
procedure at an inpatient level of care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal distraction device. 
 
You asked the Plan to pre-approve the device. You say that you would like reconsideration because the 
member has had 6 months of conservative treatment, has an FDA approved indication and the device is not 
experimental. The Plan denied your request. The Plan says the member does not have a clinical indication for 
this technology. 
 
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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is still experimental and high failure rates have been reported. More research is 
needed to show the safety and efficacy of these devices. 
 
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 a spinal distraction device.
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. You had no unusual or 
significant post-operative complications. You may benefit from multiple therapies such as physical and 
occupational therapy but the documentation does not support that your functional status requires an intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 medically necessary. The Plan 
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee underwent a right hip 
hemiarthroplasty on September 8, 2020. The physical therapy evaluation dated September 9, 2020 states she is 
weight bearing as tolerated and ambulating eight feet with a rolling walker. She needs supervision with bed 
mobility, transfers, grooming, and toileting. The complexity of her nursing, medical, and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She 
may benefit from further therapy but does not require an intensive therapy program 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 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. 
 
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 your current needs are considered custodial. 
 
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 your 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sectioning of a fixed partial denture. 
 
You asked the Plan to pre-approve the fixed partial sectioning services. You say that this is necessary. The Plan 
denied your request. The Plan says this is not covered by your plan. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
sectioning of a fixed partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that documentation does not support that a ventilator is reasonable 
and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary for the enrollee in this case. The records 
indicate that the enrollee tolerated BiPAP in the hospital without any issue and it appears the enrollee is able to 
function with BiPAP rather than the ventilator. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for a home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator 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. 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 medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but 
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy 
program. Based on the medical records provided there is no documentation that the patient requires the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled 
nursing facility level or in the home with home health services 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.
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 LTACHs are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short term acute care hospitals. In this case, 
ongoing care needs include tracheostomy care, oxygen supplementation, surveillance laboratory studies, tube 
feedings, and therapy services. The documentation does not support that the enrollee in this case requires 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 
There are no required medical services identified that are available at the LTACH, that are not available at the 
current health care setting being offered by the health plan. Consequently, the requested LTACH services are 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the CardioMEMS is indicated for those 
who have been hospitalized for heart failure in the previous year. The Plan denied your request. The Plan says 
there has not been enough research done to prove the device will improve treatment or reduce problems that 
would require hospitalization. 
 
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 the requested services. Our physician 
reviewer found that the enrollee has a history of hypertension, hyperlipidemia, hypothyroid ism, atrial 
fibrillation, aortic valve regurgitation, tricuspid valve repair, coronary artery disease and NYSHA Class III 
congestive heart failure with preserved LV ejection fraction requiring hospitalization. Therapy change based on 
data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital 
readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias 
in this trial calling into question the results. The efficacy of the CardioMEMS device is uncertain at this time 
according to leading authorities, and not recommended in current guidelines for the treatment of heart failure.  
Medicare coverage criteria are not met, since the device is still considered experimental and investigational. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - resin base, tooth #18 
(D5212). 
 
You asked the Plan to pre-approve the dental services. You say that you were hospitalized and your partials 
disappeared from the hospital and now you have no teeth and are unable to eat. The Plan denied your request. 
The Plan says you exhausted your benefit frequency limit. 
 
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. 
 
You exhausted your benefit frequency limit because you had this same service provided on June 24, 2016. 
Therefore, a new D5212 for tooth #18 would not be approved until June 24, 2021. Your EOC states that 
replacement of lost, stolen, or broken dentures less than five (5) years of age does not meet criteria for pre-
authorization of a new denture. Therefore, we decided that the Plan does not have to pre-approve mandibular 
partial denture - resin base, tooth #18 (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the enrollee does not have the Plan that covers 
acupuncture services. The enrollee's EOC states Plan members may get up to six visits per 
calendar year from network providers. Note: This benefit is not covered for all other members. Therefore, we 
decided that the Plan does not have to pre-approve acupuncture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial dentures (cast metal framework with 
resin denture bases). 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says the benefit has been exhausted for the 2020 plan year. 
 
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. The Plan covers dentures once 
every five years. 
 
You have received dentures in the last five years. Based on this information, we decided that the Plan's rules for 
coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve 
mandibular partial dentures (cast metal framework with resin denture bases).
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 enrollee requires more intensive therapy than is 
available in the current setting. The Plan denied your request. The Plan says inpatient rehab level of intensive 
therapy exceeds member's need as member does not appear to be able to tolerate intensive daily therapy and 
requires total assistance for some activities while gait is untested. 
 
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 enrollee is a male who underwent a right total knee replacement. He was 
originally sent to a different facility swing bed. A re-evaluation reveals ongoing mild-to-moderate knee pain. 
Wounds are healing and the enrollee is afebrile.  
 
Records do not indicate that there are significant, or complex medical/nursing issues that require frequent 
physician oversight or acute rehab nursing care. Ongoing pain medication and other medication management, 
wound care, and daily therapy can be provided at a lower level of care. In this case, the member is mostly 
requiring minimal to moderate assist for functional transfers and daily living activities 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Emgality.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Metronidazole. 
 
You asked the Plan to pre-approve Metronidazole. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Metronidazole.  
 
Benefits for Metronidazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.