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 enrollee has excellent potential to return to her 
higher level of functioning given the right environment, the right medical team members, and the right support.  
The Plan denied your request. The Plan says the records do not support the medical necessity of the requested 
IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Our 
reviewer also found that specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and 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 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for dislocation of an artificial hip joint. Medical problems are stable. There are no identified problems 
that need inpatient medical management. 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. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (CPT Code 64636 RT).

You asked the Plan to pre-approve the services. You say that the member is in severe pain and believe the surgery will eliminate the member's pain. The Plan denied your request. The Plan says the service is not 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 services. Our physician reviewer found the patient has not had diagnostic MBBs and also has multiple other probable pain generators. 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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (CPT Code 64636 RT).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax (71250). 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
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 a CT scan of the thorax. Our reviewer 
says that the services are medically necessary. Our physician reviewer found you satisfy CMS criteria for a low 
dose CT (LDCT) scan including age of 65 years, at least 30 years of smoking, still smoking and no 
current symptoms to suggest lung cancer. For these reasons the request for LDCT should be approved. 
 
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 CT scan of the thorax have been met. Therefore, we decided that the Plan has 
to pre-approve a computed tomography (CT) scan of the thorax (71250).  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: skilled nursing facility. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for management of fractured hip and ribs after a fall. Medical problems are stable. There are no 
identified problems that need inpatient medical management. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 
program. There is not a reasonable expectation that this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brain imaging, PET; metabolic evaluation (CPT Code 
78608). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 PET scan. Our physician reviewer 
found the review indicates that there is no specific clinical rationale for the requested PET study. The provider 
is NOT requesting a metabolic brain (FDG) PET scan to differentiate between Alzheimer's dementia vs. fronto-
temporal dementia (FTD). Provider suspects a dementing process as result of member's head injuries and 
cerebrovascular disease. The member does not meet NCD criteria for an FDG PET scan. Medicare National 
Coverage Determination (NCD) for FDG PET for Dementia and Neurodegenerative Diseases (220.6.13) 
criteria are not met. This NCD only covers FDG PET scans when a patient meets diagnostic criteria for both 
fronto-temporaldementia (FTD) and Alzheimer's disease (AD) after extensive testing listed in the NCD or its 
use in a Centers for Medicare & Medicaid Services (CMS)-approved practical clinical trial focused on the 
utility of FDG PET in the diagnosis or treatment of dementing neurodegenerative diseases. The review has 
determined that the medical records provided do not meet the requirements listed in the NCD for Medicare 
coverage. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve brain imaging, PET; metabolic evaluation (CPT Code 78608).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation 
correction and anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
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 PET scan. Our physician reviewer 
found the member has undergone prior PET scan testing for the same clinical concern on January 22, 2018. 
The member does not meet criteria for the requested PET scan, the member has already undergone the 
approvable ONE PET scan related to a suspected cancer, use of PET scan imaging as surveillance is considered 
screening in this setting and is not covered. The standard of cover would be to complete the planned guided 
biopsy of the mesenteric lymph node. The review has determined that the member does not have an indication 
for which a PET Scan can be covered 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization 
imaging; skull base to mid-thigh (CPT Code 78815).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) from 
September 28, 2020 and forward. 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF from 
September 28, 2020 and forward is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for SNF admission from September 28, 2020 and forward.. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the documentation 
provided, the enrollee did not have documented skilled nursing needs.  The enrollee did not have documented 
skilled therapy needs.  Daily skilled services were not shown to be required to establish a maintenance program 
or to prevent deterioration of the enrollee's condition.  The enrollee's care needs at this point were custodial 
and, as a practical matter, could be provided 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF) from September 28, 2020 and 
forward.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeljanz XR tab 11mg for the enrollee. 
 
You asked the Plan to pre-approve the tab. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan benefit says that medications 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 Xeljanz XR tab 11mg for 
the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the requested MRI of the lumbar 
spine is medically necessary. The Plan denied your request. The Plan says the requested MRI of the lumbar 
spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lumbar spine. Our 
reviewer says that the requested MRI of the lumbar spine is not medically necessary. Our physician reviewer 
found the enrollee is with low back pain. Based on the documentation provided, criteria for lumbar MRI have 
not been met. More conservative measures for low back pain need to be documented. There are no red flags for 
the need of an MRI 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 an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the lumbar spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires continued 
treatment. You say that the enrollee is stable and would benefit from a transfer to an LTACH. The Plan denied 
your request. The Plan says the services can be provided in another setting. 
 
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 enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: 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 Medicare coverage criteria for IRF care are not 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 based on the medical records provided, 
you do not require the intensity of services provided at an IRF.  The records do not show you require fifteen 
hours per week of rehabilitative services and regular physician evaluation. 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 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 continuation of SNF care provided from November 6, 
2020, to discharge. 
 
You asked the Plan to pre-approve continuation of SNF 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 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 continuation of SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled 
nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled 
nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility 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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of SNF care provided from November 6, 2020, to discharge.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says the 
documents do not show that the enrollee has any skilled nursing or skilled rehabilitation needs. 
 
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 admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
 
 
coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-
approve a SNF admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a permanent cardiac contractility 
modulation system (0408T). 
 
You asked the Plan to pre-approve the insertion of a permanent cardiac contractility modulation system. You 
say that this is medically necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a permanent cardiac 
contractility modulation system. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found cardiac contractility modulation has been 
shown to improve functional measures mildly, but long-term clinical benefit has not been established, and there 
is a significant risk of complications. The device is considered experimental and investigational 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 insertion of a permanent cardiac contractility modulation system have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a permanent 
cardiac contractility modulation system (0408T).