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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says LTACH admission 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 is a 67-year-old male who was admitted to the acute care hospital with 
gastrointestinal bleed, acute respiratory failure, anemia, fever, acute coronary infarction, and kidney failure 
requiring mechanical ventilation support, trach placement, antibiotics, tube feeds, and hemodialysis. Recent 
notes describe the patient as now tolerating trach collar but is in a coma and unlikely to recover according to 
the documentation. The patient appears to be more stable but not improving significantly and requires short-
term additional acute care services that can safely be performed at the current facility until more appropriate for 
a lower level of care. 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. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has 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 that the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and are able to be furnished safely and effectively 
only on an inpatient basis. The enrollee is receiving the 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: 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 patient requires LTACH admission 
because she is on a breathing tube and there is no respiratory center in the county and no skilled nursing facility 
will take her due to dialysis. The Plan denied your request. The Plan says the patient's medical needs are being 
met in the current acute setting. The LTACH would add no additional services. With additional time in the 
current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined. 
 
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 is a 49-year-old female who was admitted to the hospital on October 3, 
2022, for labial abscess. She underwent incision and drainage with washout of the labial abscess. Her hospital 
course was complicated by VRE bacteremia/ endocarditis of prosthetic aortic valve, acute on chronic renal 
failure, pneumonia and delirium. She underwent re-do Bentall procedure on October 21, 2022. Her post-op 
course was complicated by respiratory failure, and she required prolonged intubation and mechanical ventilatory support. A tracheostomy was performed on November 1, 2022. At present she is clinically 
improving. She is tolerating trach collar weaning trials during the day and continuous positive airway pressure 
(CPAP) trial at night. At this time, there is no documentation that the enrollee will benefit from and improve 
with LTACH level of care management. There is no documentation provided indicating medical necessity for 
admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee 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 the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you have a steep driveway and need the 
wheelchair to get in and out of your home. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair.
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 would like to return to prior level of 
functioning. They require OT, PT and ST. They have serious life-threatening constellation of acute medical 
problems that have left them below baseline. The Plan denied your request. The Plan says the request is not 
medically necessary, the services the enrollee needs can be provided safely in other settings, for example, a 
skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for external counterpulsation 
therapy. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the service is available in the network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for external counterpulsation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmologist. 
 
You asked the Plan to pre-approve these services. You say that this doctor did your surgery 10 years ago and 
your vision is now blurry. The Plan denied your request. The Plan says the services are available from network 
providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network ophthalmologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Greenlight laser prostate surgery. 
 
You asked the Plan to pre-approve Greenlight laser prostate surgery. You say that this surgery is medically 
necessary. The Plan denied your request. The Plan says Greenlight laser prostate surgery is not medically 
necessary because the patient's prostate currently only measures 15 cubic centimeters and there is no 
documentation of the patient's urinary symptoms and urine flow testing. 
 
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 Greenlight laser prostate surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records do not show that the enrollee has symptoms and obstruction 
due to benign prostatic hyperplasia. The records show that the prostate is of normal size and do not show a high 
symptom score, decreased flow rate on uroflow study or a high post void residual.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Greenlight laser prostate surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Greenlight laser prostate surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary for a history of 
superficial carcinoma of the skin. The Plan denied your request. The Plan says the requested service is not 
covered by Medicare or the health plan. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the the treatment itself is not disputed in this case but rather the need for image guidance. Usually 
image guided radiation therapy (IGRT) is used when critical structures are abutting or in close proximity to the 
target that is being treated to high doses. This situation does not apply to this patient for which the target lesion 
can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for 
IGRT unless deep structures are being treated. Certainly using ultrasound on a daily basis is not unreasonable 
to offer but not necessary. Therefore to bill for daily simple simulations and/or IGRT for a technology for 
which need has not been established by published data or supported by consensus guidelines (many of which recommend against treatment with these devices in general- citations below) is not 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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound-guided radiation therapy.
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 you would benefit from IRF care due to your 
medical condition. The Plan denied your request. The Plan says IRF is not medically necessary, and your needs 
can be met at a lower level of care such as skilled nursing facility (SNF). 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a femur fracture. Your medical problems are stable and you have no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve 6 additional PT sessions. You say that these additional visits should be 
covered because you were improving from physical therapy until you were sick with COVID-19, which caused 
your progress to decline. The Plan denied your request. The Plan says it has already approved 6 of the 12 
sessions that were requested.  The additional 6 sessions not approved are not medically 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 6 additional PT sessions. 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 6 more PT visits are not medically necessary. 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, that the services can be safely and effectively performed 
only by a therapist, or by or under the supervision of a therapist.  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 the patient's current condition or to prevent or slow 
further deterioration. You are already versed in a home exercise 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 6 additional PT sessions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional physical therapy (PT) sessions.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF care. The Plan 
denied your request. The Plan says that the 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 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 documentation does not support the medical necessity for admission to an 
IRF due to lack of medical complexity, and high functional level with no nursing needs. While the enrollee 
would benefit from physical and occupational therapy the enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as in 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need more therapy, and you do not want to be 
discharged. The Plan denied your request. The Plan says that the coverage criteria for continued SNF care has 
no longer 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 that you do not have documented skilled nursing or therapy needs. Your 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 continued SNF care.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiotherapy (PBT). 
 You asked the Plan to pre-approve PBT. You say that proton beam radiotherapy providers the best chance of 
reducing post-treatment complications. The Plan denied your request. The Plan says proton beam radiotherapy 
is not considered medically necessary because there is no compelling data to show that this therapy is superior 
to IMRT or image-guided radiation therapy (IGRT) for prostate cancer. 
 
The Plan follows Medicare rules. Medicare rules say that in order for PBT to be covered, the record must show 
the advantage of PBT over IMRT or other therapies. 
 
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 PBT. Our reviewer says that proton 
beam radiotherapy is not medically necessary. Our physician reviewer found there is insufficient prospective, 
long-term clinical data available to determine whether or not proton beam radiation therapy for prostate cancer 
is superior, inferior or equivalent to external beam radiation therapy, IMRT, or brachytherapy with regards to 
safety and efficacy. Recent data shows no significant differences in late (years one, two, and three) patient-
reported toxicity outcomes between proton beam therapy and IMRT.  The most recent American Urological 
Association guidelines state that PBT offers no clinical advantage over other forms of definitive treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiotherapy (PBT).