Persius/hicric huggingface dataset:
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 clinical information provided 
supports the need for LTACH care. The Plan denied your request. The Plan says the criteria for coverage of 
LTACH care have not been 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 ongoing care needs include intravenous antibiotics, hemodialysis, surveillance 
laboratory studies, 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: 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. There were no significant post-
operative complications noted. You may benefit from multiple therapies such as physical and occupational 
therapy but the documentation does not support that your functional level or activity level can tolerate or 
require 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 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 had a stroke and just got out of 
the hospital. The appellant says that physical therapy is needed at a SNF. The Plan denied your request. The 
Plan says the records show the enrollee's medical issues are stable and that there is no need for daily skilled 
nursing services. The Plan says that the enrollee is receiving adequate and necessary intensive rehabilitation at 
the inpatient rehabilitation facility (IRF). The Plan says that movement to a SNF 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically 
and has been receiving inpatient rehab services in an inpatient rehabilitation facility.  She continues to require 
maximum to total assistance with mobility and activities of daily living (ADLs).  She is tolerating an oral diet 
but still receives nutrition via a feeding tube.  She has been medically stable and does not have any complex 
wounds or parental medications. Although she has not made significant progress with therapy, there is no need 
for a transfer to a skilled nursing facility while her needs can be met at 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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperbaric oxygen therapy treatments. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is at risk for loss of limb 
due to the chronic nature of the wound. The Plan denied your request. The Plan says that the documentation did 
not establish the medical necessity of the proposed treatment. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered under 
certain medical indications. 
 
 
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 requested services. Our physician 
reviewer found that the enrollee has a Wagner Stage 3 wound and has exhausted local therapy, vascular 
management, and diabetic control. The enrollee has a sufficient grade of wound and has exhausted other 
therapy and otherwise optimized management, per the documentation provided.  Therefore, the requested 
treatments are medically indicated and reasonable. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve hyperbaric oxygen therapy treatments.  
 
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 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 after a 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. 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: 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 is not able to do outpatient 
dialysis. You also say that the enrollee is not able to sit by herself. The Plan denied your request. The Plan says 
the enrollee does not meet all of the requirements for a LTACH admission. 
 
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 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 she is currently receiving care. Our reviewer 
found that 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. Our physician reviewer also found 
that 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the medication is 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. Medicare rules say that the A/B MAC (B) may determine that Procrit is 
covered for individuals who meet certain criteria.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Retacrit have not been met. Specifically, the record indicates that the enrollee's hemoglobin was 
not between 10 and 13mg/dl. The Plan has indicated that Retacrit has been approved for 6 months under the 
enrollee's Medicare Part D benefit. Contact the Part D Plan to learn more about how and when the request will 
be processed. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services but you do not require an 
intensive inpatient rehabilitation therapy program. There is no documentation that you require the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. Care in the skilled nursing 
facility appears to be more appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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. 
You say that the enrollee will continue to benefit from physical therapy to facilitate a safe discharge and 
maximize safety. The Plan denied your request. The Plan says the enrollee has achieved improvement with 
physical therapy, such that rehabilitation services can be performed on an outpatient basis. The Plan says that a 
continued stay in acute rehab is not appropriate or beneficial and placement in a lower level of care is more 
appropriate. 
 
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 CVA on August 20, 2020. She was transferred to inpatient acute rehabilitation on September 
4, 2020 and has received inpatient rehabilitation services through September 28, 2020. All medical problems 
are stable and there are no new medical problems requiring inpatient 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. Gains from inpatient therapy have been significant but have now plateaued. 
Ongoing services can be provided in a lower level of care. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira. 
 
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 Humira.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a femoral length sock for a leg brace described by code 
L2850. 
 
You asked the Plan to pre-approve the brace sock. You say that this is not a standard sock. It is for use under 
your brace so that it does not scratch you or rub your skin while the brace is being worn. The Plan denied your 
request. The Plan says this is not a Medicare-covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that while an ankle brace is covered under the Brace 
benefit, there is no covered benefit category for socks used with braces.  
 
Although the use of this sock may be appropriate, neither Medicare nor your Plan provides coverage for this 
item. Therefore, we decided that the Plan does not have to pre-approve a femoral length sock for a leg brace 
described by code L2850.
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 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 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 appears unstable for transfer at this time, and requires additional acute 
care services at the current facility. The patient does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the patient requires that are not 
already available and covered at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary. Transfer may be considered when the patient is more stable. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says the enrollee does not require skilled 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no notes to document skilled nursing 
services. Regarding rehabilitation services, the beneficiary has received physical, speech, and occupational 
therapy. The beneficiary was at a minimal to moderate assist level with functional mobility including gait to 35 
feet twice with a rolling walker.  The beneficiary required varying assist with activities of daily living. He had 
minimal cognitive deficits. The beneficiary does not require skilled nursing or therapy services on a daily basis 
and does 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says if the prescriber uses one of the preferred agents, it will be covered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the review has 
determined that the plan requires a trial of Orthovisc and Monovisc before they will approve the requested 
drug. You have not tried and failed these drugs. There is no documentation provided indicating that the plan?s 
required drugs would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.