Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs extra assistance with simple 
daily things. The Plan denied your request. The Plan says the admission 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee is currently at inpatient 
rehabilitation. He received oral medications and has stable vital signs. He received physical, occupational, and 
speech therapy and needs maximum assistance of two for functional mobility, including walking 25 feet with a 
rolling walker. He needs varied assistance with activities of daily living. He has no skilled nursing needs. He 
has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, he does not 
require the necessary services on an inpatient basis at the SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265) and six (6) dental extractions (D7140). 
 
You asked the Plan to pre-approve the dental services. You say that you need two upper and lower set of 
dentures covered by the insurance. The Plan denied your request. The Plan says the services are not covered by 
Medicare or 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. 
 
You exhausted your benefit for 6 dental extractions because the Plan approved three (3). Your EOC states non-
surgical or surgical extractions (pulling teeth) (Three (3) procedures per calendar year. Furthermore, biologic 
materials to aid in soft and osseous tissue regeneration (D4265) is not listed in your EOC as a covered benefit. 
Therefore, we decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous 
tissue regeneration (D4265) and six (6) dental extractions (D7140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this circumstance 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. Therefore, 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 should still be considered experimental or 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
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 you are requesting 
review of denial of services. The Plan denied your request. The Plan says you exhausted your 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 twenty-four (24) 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. You exhausted your 
benefit, because you used all 24 one-way trips. The 25th 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound/skin care, and daily therapy can be provided at a SNF. In this case, you are 
mostly minimal/standby assist for functional transfers and activities of daily living (ADL's) and a less 
intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and 
predicted period. An IRF intensity is not warranted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 the SNF services. You say that the enrollee has an acute condition with new 
infections needing daily physician monitoring and frequent changes in the treatment, which clearly meets the 
criteria for coverage. The Plan denied your request. The Plan says there are no complex medical needs 
requiring skilled nursing or skilled 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral 
nutrition and medications, as well as IV medications. The enrollee had stable vital signs. The enrollee had 
routine tracheostomy care. The enrollee required assistance with mobility and activities of daily living. The 
enrollee was unable to participate with therapy. There are identifiable skilled nursing service needs, however 
they are not required on a daily basis. There are no identifiable skilled therapy service needs. The enrollee does 
not meet the 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 the 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that the hospital wants to discharge the enrollee. 
The Plan denied your request. The Plan says the admission 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
with gallbladder inflammation (cholecystitis) and had a gallbladder tube placement. She had stable vital signs 
and was alert with confusion. She received physical, occupational, and speech therapy in the hospital and needs 
maximum assistance of two for functional mobility. She needs varied assistance with activities of daily living. 
She has skilled nursing needs but does not require skilled nursing on a daily basis. She has no skilled therapy 
needs. She does not require the necessary services on an inpatient basis at the SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an upper endoscopy (43225). 
 
You asked the Plan to pre-approve an upper endoscopy. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that endoscopy procedures can only be allowed if 
abnormal signs or symptoms or known disease are present. 
 
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 an upper endoscopy. Our reviewer says 
that the services are medically necessary. Our physician reviewer found pertinent to this review, the enrollee's 
indication for esophagogastroduodenoscopy (EGD) was variceal screening in newly diagnosed hepatic 
cirrhosis with liver decompensation. This indication approves EGD under the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an upper endoscopy have been met. Therefore, we decided that the Plan has to 
pre-approve an upper endoscopy (43225).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
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 the member does not require daily skilled 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 reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. 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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IGRT is an accepted standard when justified by a plausible rationale such as difficult enrollee 
set-up (i.e obesity which would not apply to this enrollee with a BMI<20), prior radiation necessitating more 
accurate localization, abutment of the field against a critical organ (such as heart in left sided breast cancers). 
Another rationale would be initial set-up errors necessitating serial imaging. Without a plausible rationale for 
the need of IGRT for this enrollee the service is 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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image guided radiation therapy (IGRT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary, as the enrollee could 
suffer harm without these services. The Plan denied your request. The Plan says the enrollee is now seven years 
post-nephrectomy, and the guidelines do not support further surveillance imaging in an asymptomatic patient. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the 2020 NCCN 
guidelines for Renal Cell Carcinoma surveillance indicate imaging surveillance after 5 years is ONLY 
indicated in cases where the initial tumor was likely to recur based upon pathology or if there is clinical and or 
laboratory evidence to imply recurrence/metastasis. In this case the last CT was 3/13/19 at which time there 
was no sign of tumor.  A 1.3 cm low density lesion in the spleen was noted as more conspicuous than on prior 
scans.  Ultrasound was suggested if further imaging was necessary. You had definitive surgery seven years ago 
and no clinical or imaging findings to suggest tumor recurrence have been described.  Since no path report 
describing an original tumor highly likely to recur has been submitted the medical necessity of annual 
surveillance by CT has not been established.  If imaging of the solitary remaining left kidney is needed in this 
patient with chronic renal disease and contraindication to contrast ultrasound would be the procedure of choice. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the abdomen and pelvis.
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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of diabetes, hypertension and obesity who was admitted to the acute hospital on 08/16/2020 
with confusion and a fall with a left ankle (fibula) fracture. She had reduction and splinting of the fracture in 
the emergency department. Also while in the hospital she had revision of a prior lumbar spine surgery and 
treatment of spinal osteomyelitis with intravenous antibiotics. She is weak and deconditioned and is working 
with physical and occupational therapy. She is unable to walk and is moderate to maximum assist for most 
transfers and activities of daily living. She is medically stable. 
 
Based on the medical records provided 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 does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the 
medical records provided there is concern that the enrollee will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the health plans denial should be upheld.  The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care 
needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the provider will not be furnishing the Procrit and you will be 
receiving this medication at home. 
 
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 Procrit.  
 
Benefits for Procrit 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: 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 transfer to an LTACH is medically 
necessary. The Plan denied your request. The Plan says Medicare criteria for transfer are not met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient in this case appears to be still requiring acute care services, however, is 
not likely to require at least 25 additional days of acute care services, based on the notes provided. The enrollee 
does not require any services at the LTACH that are not already available at the current setting.  Therefore, this 
request for LTACH services will be considered not medically necessary at this time. Medicare coverage criteria 
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 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.