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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for management of a C7 vertebral fracture after a mechanical fall. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record does document a need for physical and occupational therapy, it does not document a 
need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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: 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 enrollee does meet LTACH 
admission criteria and her ongoing medical needs warrant an LTACH level of care to achieve a safe and 
sustainable discharge. The Plan denied your request. The Plan says the enrollee's needs can met in another 
setting such as a skilled nursing facility. 
 
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 in this case, ongoing care needs include intravenous antibiotics, surveillance 
laboratory studies, close glucose control, wound care, 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day Sensor for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are covered 
when the above criteria have been met. 
 
 
 
We looked at the file and Medicare rules. The file indicates the enrollee is testing his blood glucose four or 
more times a day. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day 
Sensor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rheumatology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you are in pain and developing raw sores. The Plan denied your request.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you need to get your PCP's approval for specialist services. The documentation in the case file did not include a referral from your primary care physician. There are insufficient records to show that the requested services are necessary at this time. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve rheumatology services to be provided by an out of network (OON) provider.
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgery for an incarcerated hernia. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
does document a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient 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: 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 records do not show that the enrollee needs medical 
practitioner assessment or intervention 3 or more times per week, and an IRF admission 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. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires or can tolerate 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) treatments. 
 
You asked the Plan to pre-approve the Keytruda treatments. You say that this treatment should be allowed for 
this enrollee's disease. The Plan denied your request. The Plan says the enrollee's cancer does not meet the 
criteria for this treatment. 
 
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 Keytruda treatments. Our reviewer 
says that the requested treatment is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is an 80-year-old with anaplastic metastatic thyroid cancer with 
(programmed death ligand-1) PD-L1 results of 80%. Keytruda is not FDA-approved for treatment of this 
condition unless there is a high mutational burden as evidenced by a Combined Positive Score (CPS) of at least 
10, not based on PD-L1. There is also no support for this treatment in one of the major drug compendia or 
CMS-approved medical journals. 
 
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 Keytruda treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Keytruda (pembrolizumab) treatments.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan 
denied your request. The Plan says there are in-network providers able to provide care. 
 
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 
the medical services to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - one to three teeth 
per quadrant (D4342), retainer crown - porcelain fused to predominantly base metal (D6751), overdenture - 
partial maxillary (D5864) and pontic - porcelain fused to predominantly base metal (D6241). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot wait thirty (30) days to get your 
teeth done. The Plan denied your request. The Plan says the services are not a covered benefit under the 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. The services are not listed in your handbook as a covered benefit; 
therefore, they are not covered. Therefore, we decided that the Plan does not have to pre-approve periodontal 
scaling and root planing - one to three teeth per quadrant (D4342), retainer crown - porcelain fused to 
predominantly base metal (D6751), overdenture - partial maxillary (D5864) and pontic - porcelain fused to 
predominantly base metal (D6241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seat lift mechanism, electric, any type (CPT Code 
E0627) and transfer bench for tub or toilet with or without commode opening (CPT Code E0247). 
 
You asked the Plan to pre-approve the DME. You say that the enrollee is in dire need for a bariatric seat lift 
mechanism because they need assistance in standing from a regular chair due to increased shortness of breath 
upon standing. The Plan denied your request. The Plan says the medical information they received shows that 
the enrollee does not have any necessary information about their condition and the need for the device. 
 
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 DME. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not meet the Medicare LCD L33801, Seat Lift Mechanisms criteria. 
The documentation does not reveal objective evidence that the patient has severe arthritis of the hip. The 
documentation does not reveal that the patient has a neuromuscular disease. The documentation indicates an 
appeal from the patient's nurse practitioner provider for a bariatric seat lift. The documentation does not support 
that a seat lift is likely to affect improvement in the patient's condition or arrest or retard deterioration in the 
patient's condition. The records do not indicate that the patient is completely incapable of standing from a chair. 
The records do indicate the patient can ambulate. Per Social Security Act, Section 1862 (a)1(A) and the 42 
CFR Section 411.15(k), the requested transfer bench for tub or toilet with or without commode opening (CPT 
Code E0247)] is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. Currently September 20, 2020, home health notes indicate the 
patient has a tub/shower bench and is at a supervision level for bathing and toileting hygiene with goals of 
independence. The requested bench does not appear to be medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve seat lift mechanism, electric, any type (CPT Code E0627) and transfer bench for tub or toilet 
with or without commode opening (CPT Code E0247).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require 
physician supervision, or a multidisciplinary team for care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that you are at a maximum assist level for bed rolling, sitting up, scooting, and lying down. You are unable to 
stand or ambulate at this time. You are dependent for bathing and personal care. You do not require the 
intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per 
week of rehabilitative services with regular physician evaluation. 
 
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 implantation or replacement of device for intrathecal or
epidural drug infusion; programmable pump, including preparation of pump, with or without programming
(CPT Code 62362) and implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for
long-term medication administration via an external pump or implantable reservoir/infusion pump; with
laminectomy (CPT Code 62351).
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 medical record says the enrollee already has an implanted spinal cord stimulator.
The Plan states the enrollee continues to have breakthrough pain despite the stimulator and oral medications.
The Plan states Medicare rule says that a pain pump is not covered when a member has other implanted
programmable devices.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer
found the patient has a spinal cord stimulation (SCS) in place that is not relieving their pain. The NCD and
LCD precludes the placement of an intra-thecal pump in the presence of a SCS. The SCS would have to be
explanted before a pump could be considered. At this point, the request is considered not medically reasonable
or 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve implantation or replacement of device for intrathecal or epidural drug infusion;
programmable pump, including preparation of pump, with or without programming (CPT Code 62362) and
implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication
administration via an external pump or implantable reservoir/infusion pump; with laminectomy (CPT Code
62351).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional physical therapy services for a total of 8. 
 
You asked the Plan to pre-approve 2 additional physical therapy services. 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 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 2 additional physical therapy services. 
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 you have had extensive therapy for this 
condition and it does not appear that you require the ongoing 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 authorized additional sessions to review an independent 
 
 
exercise program and ensure safety. The 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. Therefore, you do not meet criteria for the requested additional physical therapy 
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 2 additional physical therapy services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 2 additional physical therapy services for a total of 8.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve Xarelto. 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 Xarelto.  
 
Benefits for Xarelto may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.