Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the records did not show the need for a doctor visit at least three times 
per week. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require 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. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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 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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the enrollee is medically stable and admission to an IRF 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 medical records provided do not show that the complexity of the enrollee's 
nursing, medical, and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires physical therapy and occupational therapy, but not in an 
intensive inpatient rehabilitation therapy program. 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 IRF. Care at a 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says that the member is receiving appropriate in-
patient acute care and does not require transfer to LTACH. 
 
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. The patient 
appears to be improving but not yet stable enough to transfer at this time as she requires additional acute care 
services for the short-term. The patient does not require any services at the LTACH that are not already 
available at the current facility. Continued care at the current facility is appropriate until stable enough for 
discharge to a lower level of care at a later date. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for LTACH 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 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 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 your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical 
records provided you do not require an intensive inpatient rehabilitation therapy program. Based on the medical 
records provided 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. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve test strips. 
 
You asked the Plan to pre-approve these services. You say that you would like these to be covered. The Plan 
denied your request. The Plan says that they were unable to obtain medical reason from you physician as to 
why the preferred product cannot be used. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers. 
 
The items at issue are test strips. This provider is not a preferred provider with the Plan for diabetic supplies. 
Therefore, we decided that the Plan does not have to pre-approve the test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy provided on April 21, 2020. 
 
You asked the Plan to pay for the endodontic therapy. You say that you were under the impression that your 
policy covered a root canal. You also say that you are on a limited income and could use help paying for this 
service. The Plan denied your request. The Plan says this service is not covered. 
 
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 pay for the 
endodontic therapy provided on April 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computerized tomography (CT). 
 
You asked the Plan to pre-approve a low dose CT. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that low dose CT scans are only covered for enrollees 
between the ages of 55 and 77. 
 
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 low dose CT. Our reviewer says that 
the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has an age of 79. Therefore, the enrollee does not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Review of the file shows that the enrollee is 
not between the ages of 55 and 77. Based on this information, we decided that Medicare rules for coverage of a 
low dose CT have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose 
computerized tomography (CT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy (unilateral 
or bilateral with decompression of spinal cord, single vertebral segment; lumbar (CPT Code 63047) and 
laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], single vertebral segment; each additional segment, cervical, thoracic, or lumbar 
(CPT Code 63048). 
 
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 necessary. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient has a diagnosis of failed back surgery and chronic lower back pain (LBP). There is a 
magnetic resonance imaging (MRI) showing L3-4 stenosis, but the study is older than 6 months. A new MRI 
within six (6) months is needed to see if the pathology has changed. Criteria for surgery are not met. 
 
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 laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression 
of spinal cord, single vertebral segment; lumbar (CPT Code 63047) and laminectomy, facetectomy and 
foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], 
single vertebral segment; each additional segment, cervical, thoracic, or lumbar (CPT Code 63048).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel, Pembrolizumab for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the mix of the requested drugs is not supported in the guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the requested use of 
these drugs for metastatic squamous cell cancer of the skin is not FDA approved or supported in any of the 
CMS approved compendia. The combination of drugs is supported for treatment of metastatic squamous cell 
lung cancer. However the documentation does not indicate that is the enrollee's diagnosis. Therefore, the 
documentation does not support that the combination requested is medically reasonable and necessary for the 
enrollee. The documentation does not support the requested combination is safe and effective for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Carboplatin, Paclitaxel, Pembrolizumab for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health services. 
 
You asked the Plan to pre-approve inpatient behavioral health services. 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 inpatient behavioral health services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based upon review of the records provided, the enrollee does not meet 
the criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself 
or others. The enrollee was without agitation or aggression and without perceptual disturbance including 
auditory, visual hallucinations or delusions. The enrollee was not going through any acute symptoms of 
withdrawal. 
 
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 behavioral health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behavioral health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee prosthesis to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve a below knee prosthesis to be provided by an OON provider. You say that 
the items are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these items. Therefore, coverage criteria has not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a below knee prosthesis to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this procedure is helpful for treatment of the health 
problem. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found criteria for surgery not met. There is no recent trial and failure of PT for back pain. Surgery not needed. 
Also, bone marrow aspiration remains experimental at this time. It is not medically needed. 
 
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 bone marrow aspiration for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous access and closure of femoral artery for 
delivery of endograft through a large sheath services provided on May 14, 2020. 
 
You asked the Plan to pay for the percutaneous access and closure of femoral artery for delivery of endograft 
through a large sheath services. You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 34713 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the percutaneous access and closure of 
femoral artery for delivery of endograft through a large sheath services have not been met. Therefore, we 
decided that the Plan does not have to pay for the percutaneous access and closure of femoral artery for 
delivery of endograft through a large sheath services provided on May 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided from December 10, 
2019 to March 12, 2020. 
 
You asked the Plan to pay for home infusion therapy services. You say that you are appealing with records. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
code is not valid for Medicare purposes and is not allowed for payment to an out-of-network provider. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy services have not been met. Therefore, we decided that the Plan does not 
have to pay for home infusion therapy services provided from December 10, 2019 to March 12, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require 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. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22870, 22869). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. 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 a Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Veriflex spacer and all other spinous process spacers remain 
experimental at this time. More research is needed to show safety and efficacy. The surgery is not needed. 
There is no spinal instability documented. 
 
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 Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22870, 22869).