Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical needs are being met in the current acute care 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 you appear to be improving and more stable and should only require short-term 
additional acute care services that can safely be administered at the current facility until appropriate for a lower 
level of care. 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 has 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 admission to a long-term acute care hospital (LTACH).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of an impacted tooth represented by code 
D7240, and veneers represented by code D2962. 
 
You asked the Plan to pre-approve codes D7240 and D2962. You say that you are insecure about your teeth 
and would like to improve them. The Plan denied your request. The Plan says the services in dispute are not 
covered benefits under your contract. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of an impacted tooth represented by code D7240, and veneers represented by code D2962.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab. 
 
You asked the Plan to pre-approve Nivolumab. You say that this drug is medically reasonable and necessary 
for the enrollee's condition. The Plan denied your request. The Plan says there are not enough studies to prove 
this treatment works well for the enrollee's condition. 
 
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 Nivolumab. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with stage I adenocarcinoma of the esophagus. They are currently status post chemotherapy and 
radiation. In this case, there is no FDA-indication for the requested drug and the enrollee's condition. 
Furthermore, per the National Comprehensive Cancer Network compendia, Nivolumab is preferred 
postoperative therapy for patients who have received preoperative chemoradiation and R0 resection and 
residual disease. As this patient did not have surgery, they are not a candidate for Nivolumab.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nivolumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nivolumab.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continuation of SNF care from March 20, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before March 19, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continuation of SNF care from March 20, 2022, forward.  
 
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 inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient psychiatric services. You say that the records provided support the 
need for inpatient psychiatric care. The Plan denied your request. The Plan says the enrollee no longer meets 
the criteria or an inpatient level of care. The Plan says that the enrollee could be treated safely and effectively at 
a lower level of care. 
 
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 psychiatric services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found it was not 
expected this enrollee would improve in a reasonable period of time for the dates in question as she did not 
have suicidal or homicidal ideation, auditory or visual hallucinations. The enrollee was 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 she did not have dangerousness to self or others and was compliant with her treatment. It 
did not appear that the services were reasonably expected to improve the enrollees condition or for the purpose 
of diagnosis beyond the date in question. The enrollee was cooperative/compliant with treatment while not 
showing any threats to safety. 
 
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 psychiatric services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D295500) on tooth #3, a crown (D2740) on tooth #3, gingivectomy or gingivoplasty, one to three contiguous 
teeth (D4211) on tooth #Q10 and occlusal adjustment (D9951) on tooth #3. 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of services. 
The Plan denied your request. The Plan says the enrollees dental plan design outlines that there are certain 
services which require pre-authorization. The services denied, were determined to be services that are not 
required by the enrollee based on the dental guidelines outlined. 
 
 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found there is a defective restoration in tooth #3, 
however there does not appear to be significant coronal breakdown to warrant a core buildup and crown 
restoration. There was no indication as to why a gingivectomy or gingivoplasty was required (periodontal 
charting was not included). Occlusal adjustment is not a service that would be required if these treatments were 
done. Therefore, on the basis of the documentation provided, the criteria for coverage have not been met for 
any of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve core buildup, including any pins when required (D295500) on tooth #3, a crown (D2740) 
on tooth #3, gingivectomy or gingivoplasty, one to three contiguous teeth (D4211) on tooth #Q10 and occlusal 
adjustment (D9951) on tooth #3.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this request cannot be approved at this time. 
 
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 should only require short-term additional acute care 
services that can safely be administered at the current facility until more appropriate for a lower level of care. 
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 may be considered 
when treatment has 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 admission to a long term acute care hospital 
(LTACH).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires 
a trial of Avastin before it will approve Vabysmo. 
 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 Vabysmo. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Vabysmo. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drug of Avastin. There is no documentation that 
the preferred drug would likely be less effective and/or have adverse effects for 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Vabysmo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the 
enrollee could receive care 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 the enrollee is medically becoming stable and does not need physical medicine 
and rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. There are no rehabilitation nursing needs 
identified or documented in the record. He is getting fatigued quickly per therapy notes and will not be able to 
tolerate IRF level of intensity. The enrollee will not tolerate and 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. 
His rehabilitation can be provided in a skilled nursing facility (SNF) when more stable. IRF admission is not 
medically necessary based on lack of medical complexity, and lack of rehabilitation nursing needs and poor 
endurance. Documentation does not support the necessity for admission to an IRF. While the enrollee may 
benefit from physical therapy and occupational therapy, the enrollee's rehabilitation can be safely provided at a 
lower intensity and alternate setting such as in an SNF. 
 
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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 the patient was admitted for ischemic changes to the foot and had a below the knee 
amputation followed by an above the knee amputation. 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. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. In conclusion, 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 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 Group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that you need this particular wheelchair 
for precision. The Plan denied your request. The Plan says you do not have a condition for which a Group 3 
power wheelchair may be covered. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair with accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you cannot move around with moderate 
help. You say that you need maximum help to move around. You say that you are not ready for part-time 
skilled services and still needs skilled services on a daily basis. The Plan denied your request. The Plan says the 
guidelines for coverage 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely 
and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. 
The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled 
nursing SNF need. The enrollee's wounds are improving and do not require a skilled nursing in a SNF. The 
enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination 
of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary 
services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 
 
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 a continuation of skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex procedure is experimental. More research is needed to show safety and 
efficacy. 
 
 
 
 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
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 is not safe to discharge home. The Plan 
denied your request. The Plan says the denial of authorization for SNF care is correct. 
 
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 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 skilled nursing facility (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 skilled nursing facility (SNF) care.