Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 one-hour skilled nursing visits per day for 60 days 
(G0299/G0300) and 14 hours per week of home health aide services for 9 weeks (G0156). 
 
You asked the Plan to pre-approve 4 one-hour skilled nursing visits per day for 60 days and 14 hours per week 
of home health aide services for 9 weeks. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 4 one-hour skilled nursing visits per 
day for 60 days and 14 hours per week of home health aide services for 9 weeks. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee is noted to be a diabetic, who 
receives home nursing visits to administer his insulin four times a day. It is not necessary for a visiting nurse to 
be present for one hour in order to provide this service. The request for four, one-hour-long nursing visits per 
day is not medically necessary or reasonable. This service can reasonably be provided within the half-hour-
long visits approved by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 one-hour skilled nursing visits per day for 60 days and 14 hours per week of 
home health aide services for 9 weeks have not been met. Therefore, we decided that the Plan does not have to 
pre-approve 4 one-hour skilled nursing visits per day for 60 days (G0299/G0300) and 14 hours per week of 
home health aide services for 9 weeks (G0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture and a complete maxillary 
denture. 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 a 
mandibular partial denture and a complete maxillary denture.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF System. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has NYSHA Class III 
congestive heart failure with preserved left ventricular ejection fraction (LVEF 55%) requiring hospitalization. 
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. 
Concerns have been raised about potential bias in this trial, calling into question the results. The efficacy of the 
CardioMEMs is uncertain at this time and the services are considered experimental/investigational in nature. 
The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs HF System.
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 for the enrollee. 
 
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 enrollee can safely receive the services needed 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 
patient is generally medically stable with Debility from COPD exacerbation with no evidence of complex 
medical issues that require monitoring by an inpatient physical medicine and rehab physician three times per 
week or need for acute rehab nursing care. While she may benefit from continuing physical therapy (PT) and 
occupational therapy (OT), there is no evidence of need for an intensive therapy program at the current 
functional tolerance level with therapy 3 hours per day with frequent physician oversight and an 
interdisciplinary approach to rehabilitation care.  
 
Admission to IRF is not medically necessary based on lack of medical complexity and current functional status 
and inability to endure therapy without rest breaks. She will not tolerate IRF level of therapies and does not 
need them either. The enrollee's rehab needs can be met at an alternate, low intensity level setting. Our 
physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure is considered experimental and investigational. 
 
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 this is considered an experimental/ investigational procedure and you are not enrolled in a clinical trial. It 
is the subject of ongoing clinical trials. Therefore, 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 genicular nerve radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission 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 you were admitted to the current acute care hospital with dizziness, speech difficulty, 
and difficulty reading. A CT scan showed large left temporal mass. You were treated with craniotomy and 
tumoral debulking and left temporal lobe resection. After surgery you had experienced confusion and 
disorientation requiring restraints. Recent notes suggest some mental status improvement but agitation is still 
intermittent, being treated with Keppra, steroids, Haldol, and Seroquel. The documentation does not support 
that you require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tresiba Flextouch injection 100 unit for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan does not cover outpatient prescription drugs. 
 
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 Tresiba Flextouch injection 
100 unit for the enrollee.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the requirements for coverage of IRF care have 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 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 requires or that his  endurance level 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 tramadol HCl. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 tramadol HCl.  
 
Benefits for these services 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 skilled nursing visits, 8 occupational therapy visits, 
and 9 speech therapy visits. 
 
You asked the Plan to pre-approve additional skilled nursing visits, occupational therapy visits, and speech 
therapy visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional skilled nursing visits, 
occupational therapy visits, and speech therapy visits. 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 had prior skilled nursing visits for disease and medication management and education. The 
enrollee's conditions are chronic and there is no evidence of complex wound care or other skilled nursing need. 
The documentation supports that the enrollee's caregiver expressed understanding of a home exercise program 
in speech therapy. The documentation does not support that  skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional skilled nursing visits, occupational therapy visits, and speech therapy 
visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 skilled nursing 
visits, 8 occupational therapy visits, and 9 speech therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health treatment. 
 
You asked the Plan to pre-approve inpatient mental health treatment. 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 mental health treatment. 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, you do not meet the criteria for 
continued acute inpatient mental health treatment for the dates in question of August 13, 2020 forward as you 
were not shown to be a danger to yourself or others. You were not showing any auditory or visual 
hallucinations and were cooperative/compliant with treatment while not showing any threats to the safety of 
yourself or others. 
 
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 mental health treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of the extremity veins. 
 
You asked the Plan to pre-approve the duplex scan of the extremity veins. You say that the clinical 
documentation provided supports the need for the requested scan. The Plan denied your request. The Plan says 
there is an approval code for the same study, or a similar study. The Plan says that the guidelines do not support 
additional imaging without knowing the outcome of the prior approval. 
 
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 duplex scan of the extremity veins. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee had bilateral ultrasound studies completed on April 30, 
2020 and again on June 26, 2020. The study from June 26, 2020 showed no change over that interval. The 
beneficiary has had no changes in treatment during that interval as well. Given the stability in the April 30, 
2020 and June 26, 2020 studies, no clinical findings during that interval and no new treatment during that time 
frame, it does not appear to be medically necessary to establish yet another set of baseline studies. 
 
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 duplex scan of the extremity veins have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a duplex scan of the extremity veins.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET/CT scan. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says imaging may be supported when the records include CED notes that show a clinical trial 
or registry. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 CMS guidelines per 
NCD criteria specify that one PET A Beta Amyloid scan will be approved provided the patient is enrolled in a 
CMS approved clinical trial and meets certain clinically relevant criteria as well. The submitted records do not 
show this enrollee is enrolled in such a trial thus does not meet CMS criteria for the scan. 
 
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 a PET/CT scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prednisone. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 prednisone.  
 
Benefits for these services 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 the enrollee is not in condition to be 
discharged. The Plan denied your request. The Plan says that transfer to an LTACH would add no additional 
services. 
 
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 
is currently undergoing treatment at an acute care hospital (ACH) for congestive heart failure. The enrollee is 
not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. 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.