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

 
We decided that the Plan does not have to pre-approve the Procrit. 
 
You asked the Plan to pre-approve the Procrit. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Procrit. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
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 Procrit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Procrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hand control for a wheelchair. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve hand control for a wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 7, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider reported routine lab services related to the treatment of end stage renal disease 
(ESRD), which does not follow industry standard coding rules 
 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower/bath chair. 
 
You asked the Plan to pre-approve a shower/bath chair. You say that a shower/bath chair is medically 
necessary. The Plan denied your request. The Plan says a shower/bath chair is not covered by Medicare under 
any circumstance. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower/bath chair.
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 you need to be in rehab as soon as possible. The Plan 
denied your request. The Plan says the member's medical and therapy needs could be met in a skilled nursing 
unit. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  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 that the complexity of your nursing, medical and rehabilitation needs do not require 
an interdisciplinary approach to rehabilitation care in an inpatient acute rehabilitation facility at this time. 
While you may benefit from additional multiple therapies, the documentation does not support that you require 
or can tolerate any therapy on an intensive IRF level. 
 
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 she should be transferred to an LTAC to 
receive the necessary vent weaning, nutritional assessment and therapy required to prevent any worsening 
conditions. You say that the enrollee currently meets acute LTACH admission criteria under CMS guidelines 
and is the most appropriate care available for her daily medical management needs. The Plan denied your 
request. The Plan says care can safely be received 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving care. The enrollee is receiving appropriate care at the 
present 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure Plus (4 cans per day). 
 
You asked the Plan to pre-approve Ensure Plus. You say that Ensure Plus is medically necessary. The Plan 
denied your request. The Plan says oral nutritional supplements are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.  
Ensure Plus is a nutritional supplement. Although these may be appropriate, neither Medicare nor the Plan 
provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Ensure Plus (4 
cans per day).
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 did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says you do not require transfer to an LTACH. You can 
continue to stay at the current acute hospital until stable enough for discharge. 
 
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 appear to be improving and stable and only require short-term additional acute 
care services including additional oxygen weaning that can be safely administered at the current facility. You 
do not require services at the LTACH that are not already available at the current facility. Transfer to LTACH 
is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be 
considered when treatment is completed.  
 
 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. The Plan denied your request. The Plan says your ongoing skilled 
therapy and nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  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 that you do not need intensive therapies, consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. While you may benefit 
from physical therapy and occupational therapy, your rehab can be safely provided at a lower intensity and 
alternate setting such as a skilled nursing 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 IRF admission and services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health services from 4/11/2022 on. 
 
 
You asked the Plan to pre-approve inpatient mental health services from 4/11/2022 on. You say that you would 
like reconsideration because active treatment was still taking place. The Plan denied your request. The Plan 
says your condition has improved and you are no longer a threat to yourself. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 services from 
4/11/2022 on. Our reviewer says that it was not expected you would improve in a reasonable period of time for 
the dates in question as you did not have suicidal or homicidal ideation, auditory or visual hallucinations. You 
were compliant with treatment while not showing any acute threats to safety. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question as you did not have dangerousness to self or others and were 
compliant with your treatment. Our physician reviewer found it did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services were reasonably expected to improve your 
condition or for the purpose of diagnosis beyond the date in question. 
 
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 services from 4/11/2022 on have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient mental health services from 
4/11/2022 on.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the total knee arthroplasty (TKA). 
 
You asked the Plan to pre-approve the TKA. You say that you would like reconsideration because you are 
completely incapacitated, unable to ambulate, and need the surgery. The Plan denied your request. The Plan 
says the records do not document why a more reasonable attempted trial of non-surgical medical management 
of your knee pain is not appropriate for you. 
 
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 TKA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that you have had an adequate trial and failure of conservative 
measures for knee degenerative joint disease. A recent trial of Physical Therapy is needed. 
 
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 TKA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the total knee arthroplasty (TKA).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary to help reduce pain. The 
Plan denied your request. The Plan says there is an established home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the additional requested therapy generally is not accepted as specific and 
effective therapy for your condition beyond what was approved by the plan. You have had prior therapy, and 
the documentation does not reveal that you require the unique skills of a professional therapist to safely and 
effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or 
by or under the supervision of a therapist. You have been instructed in a home exercise program. Your 
functional level and deficits do not require ongoing skilled professional therapy. The requested services are not 
part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow 
further deterioration. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 14 physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 in the Medicare rules section 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 care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documented skilled nursing 
or skilled therapy needs. 
 
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 care have not been met. Specifically, medically necessary service can 
be obtained in a lower level of care. Therefore, we decided that the Plan does not have to pre-approve the 
skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you still have problems with your leg and 
you don't have any help at home. The Plan denied your request. The Plan says you no longer meet SNF criteria 
as of April 8, 2022. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found as of April 8, 2022, you had no 
identifiable skilled nursing or skilled therapy needs. You do not require these services on 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continued acute care 
to prevent further complications. The Plan denied your request. The Plan says the enrollee has not completed 
the full course in the hospital. 
 
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 physician 
reviewer found that the enrollee is being treated at the acute care hospital for prolonged respiratory failure. He 
currently requires high-flow oxygen. The enrollee is receiving appropriate care at the present acute care 
hospital. He does not require services at the LTACH that are not available at the acute care hospital where 
he/she is currently receiving care. There are no services available at the LTACH that he requires that are not 
available at the health care setting being offered by the health plan. Therefore, the requested LTACH services 
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF 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 in the Medicare rules section. 
 
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 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 cervical spine surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heating pad. 
 
You asked the Plan to pre-approve a heating pad. You say that a heating pad is medically necessary. The Plan 
denied your request. The Plan says a heating pad is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  A heating pad does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a heating pad.