Persius/hicric huggingface dataset:
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 services are medically necessary. The Plan 
denied your request. The Plan says rules for coverage of this service have not been met. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not shown to be required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs can 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 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: 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 medical complexity cannot 
be managed at a lower level of care, and they are at great risk for readmission to a short-term acute care 
hospital if not placed appropriately. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee's needs 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 acute 
care hospital where they are currently receiving care. The health plan has approved ongoing care in the current 
acute care setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 60mg/mL subcutaneous syringe for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria has not been met. 
 
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 that in this case, the 
record indicates that the enrollee has age related osteoporosis without osteoporotic fracture.  The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's 
preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would 
have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are 
not satisfied. 
 
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 Prolia 60mg/mL subcutaneous syringe for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has developed a deep cough, and 
weakness. You say that the enrollee is requiring assistance with all bed mobility and going to the bathroom. 
The Plan denied your request. The Plan says a SNF admission is not medically necessary, and the enrollee's 
needs can be met at an alternate lower level of care. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has identifiable skilled nursing service needs but does not have 
identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a 
daily basis as an inpatient 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 build up strength to be able to take better 
care of yourself at home. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and you can safely receive the services you need in another setting. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 23, 
2022, to April 20, 2022. 
 You asked the Plan to pay for SNF care. You say that you would like this denial to be reconsidered. The Plan 
denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an 
inpatient SNF level of care. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided, there is no documentation that the patient 
required skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a 
skilled professional nurse or qualified therapist were not required to safely and effectively provide medically 
necessary and reasonable treatment from 04/16/2022 through 04/20/2022. The records did not document the 
need for intravenous medications, new tube feeding or ostomy care or daily complex wound care or respiratory 
care. The patient was walking greater than household distances with a wheeled walker with stand-by assistance 
and was supervision for transfers and was supervision to contact guard assist for activities of daily living. 
These services appear to have been custodial 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 23, 2022, to April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Treatment (IMRT) 
(77014, 77386). 
 
You asked the Plan to pre-approve IMRT. You say that the enrollee has nose cancer and needs IMRT therapy 
because it is the only thing available in the memory cannot drive to another facility to get it. The Plan denied 
your request. The Plan says the provider wants to use IMRT to treat the enrollee's cancer. The request does not 
meet the Medicare or health plan coverage criteria. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT is medically necessary when other forms of external beam radiation cannot be as 
effective either with respect to efficacy or toxicity. With skin cancers, there are innumerable ways to treat 
radiation. With respect to external beam radiation, orthovoltage radiation (low energy) or electron beam 
radiation are standard approaches, though few own orthovoltage machines. IMRT is generally accepted when 
treating nodal regions, or large and complex surfaces, neither of which seem to be the case with the enrollee 
who was offered radiation for a 3 mm nasal ala basal cell carcinoma. The most recent NCCN guidelines cite a 
paper on the use of IMRT for advanced skin cancer, though do not specifically discuss IMRT. Nothing in the 
case file supports the need for IMRT other than the office not being able to offer standard electron therapy. If 
this were the only practice in network, then out of network treatment would be necessary, and if that was 
burdensome then demonstrating the need for IMRT over 3D conformal radiation would be needed. As IMRT 
would not be furnished in accordance with accepted standards of practice and the LCD, 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 IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity Modulated Radiation Treatment (IMRT) (77014, 77386).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with Auto-EPAP 
(AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that in this 
case, the record indicates that the enrollee has chronic hypercarbic respiratory failure from chronic obstructive 
pulmonary disease. The record indicates that the enrollee was successfully treated with BiPAP in the 
hospital.  The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with 
AVAPS capability. The plan has indicated coverage for such a device is available upon request. The elements 
of the coverage criteria are not satisfied. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
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 needs medical oversight for complexity 
due to acute diagnosis. You say that the enrollee is refusing to go to skilled nursing facility, however if they are 
not in a rehabilitation facility the enrollee will go home against medical advice. The Plan denied your request. 
The Plan says an IRF admission is not medically necessary, and the enrollee's needs can be met at an alternate 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an off-label, 
not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Botox. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that Botox 
is not FDA-approved for treatment of dysphagia, unspecified, esophageal stricture, delayed gastric emptying 
and history of esophageal cancer. Furthermore, the use of Botox for treatment of dysphagia, unspecified, 
esophageal stricture, delayed gastric emptying and history of esophageal cancer is not supported by one of the 
major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan has no contractual obligation to cover additional physical therapy that are not 
reasonable and necessary. 
 
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. 
The requested additional visits are not medically reasonable or necessary. Our physician reviewer found that in 
this case, the enrollee has previously been treated with outpatient therapies and should be independent with a 
home exercise program. There is no documentation of a recent injury or decline in function. The additional 
therapy services are not an appropriate duration and frequency for treatment of the enrollees medical condition 
and therefore are not 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ten additional physical therapy visits.
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 requires a short stay at an IRF which 
could allow them the best outcome to return to home setting and avoid risk of falls and costly readmission. The 
Plan denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee can 
safely receive the care they need in another setting. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: 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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found records do not document the need for intravenous medications, new tube feeding, 
ostomy care, daily complex wound care or respiratory care. There is no documentation that daily skilled 
services are required. Although records document the enrollee is very limited functionally, provided records do 
not document a significant decline in the enrollee's functional status compared to her recent baseline to 
necessitate daily inpatient skilled therapy services. There is no documentation that the enrollee requires the 
services on an inpatient basis, only in a skilled nursing facility setting. Records do not support that services in a 
long-term care facility on a part time basis are not 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.