Persius/hicric huggingface dataset:
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 has significantly declined in functional 
mobility and has had an increase in falls at home. The Plan denied your request. The Plan says that the 
admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 enrollee does not have complex nursing or rehabilitation needs. 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. There is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 admission to the SNF is medically necessary. The 
Plan denied your request. The Plan says you do not meet the medical necessity and established criteria for a 
SNF admission. 
 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. 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 SNF care.
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 enrollees needs SNF care. The Plan denied your 
request. The Plan says a SNF admission 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 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 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 or skilled therapy 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous nerve. 
 
You asked the Plan to pre-approve a thermal destruction of intraosseous nerve. You say that you would like 
this service to be approved for the enrollee so they can obtain the relief they deserve. The Plan denied your 
request. The Plan says medical necessity has not been met. 
 
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 a thermal destruction of intraosseous 
nerve. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found documentation was/is lacking regarding reasonably 
detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary 
generators of the enrollees chronic persistent pain. Documentation does not support actual formal surgical 
ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. Our 
reviewer found that there is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Our physician reviewer also found that the requested 
intracept intraosseous basivertebral nerve ablation at the L4 and L5 vertebral bodies, in this case, is not 
medically reasonable or 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 a thermal destruction of intraosseous nerve have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a thermal destruction of intraosseous nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible protective outer surface covering system. 
 
You asked the Plan to pre-approve a flexible protective outer surface covering system. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems (L5962, 
L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. 
 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 a flexible protective outer surface 
covering system. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found a specialized lower limb prosthetic cover (L5962) exceeds the enrollee's medical needs. The 
documentation does not support that the enrollee has special needs for protection against unusually harsh 
environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of 
protection that is afforded by a standard prosthetic cover. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a flexible protective outer surface covering system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a flexible protective outer surface covering 
system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 119 additional units of anesthesia provided to the enrollee on 
June 30, 2022. 
 
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 no additional records were received after five attempts. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. Despite 
multiple attempts by the plan, records to support the billing of the additional units was not received in this case.. Therefore, we decided that the Plan does not have to pay for 119 additional units of anesthesia provided 
to the enrollee on June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided from May 24, 2022, through 
May 31, 2022. 
 
You asked the Plan to pay for the hospital services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the enrollee was enrolled in hospice at the time of services. The Plan states per 
Medicare guidelines, the enrollee's services should be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on May 16, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital services 
provided from May 24, 2022, through May 31, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Orthovisc injections. 
 
You asked the Plan to pre-approve Orthovisc injections. You say that in the past, Orthovisc injections have 
substantially improved your mobility and knee discomfort. You also say that currently, your knee pain is 
hindering you from being able to perform daily living activities and maintain the fitness routine prescribed by 
your physical therapist. The Plan denied your request. The Plan says that Orthovisc injections for osteoarthritis 
in your bilateral knees are not medically necessary at this time. 
 
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 Orthovisc injections. Our reviewer says 
that this service is reasonable and necessary for you. Our physician reviewer found the record indicates that 
you have a diagnosis of osteoarthritis of the knee. The record indicates that you have failed simple analgesics 
and received the requested agent with good result in January 2022. Our reviewer found that the FDA has stated 
that the requested drug is indicated for your condition. The elements of the coverage criteria are satisfied.  Our 
physician reviewer also found that the requested service 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 Orthovisc injections have been met. Therefore, we decided that the Plan has to 
pre-approve Orthovisc injections.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Remede phrenic nerve stimulator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a phrenic nerve stimulator is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has heart failure with 
reduced ejection fraction (HFrEF) due to ischemic cardiomyopathy, ejection fraction most recently at 25 
percent, and severe central sleep apnea (CSA). The Remede device has not been studied sufficiently in blinded 
randomized trials, or compared with PAP treatment, to justify it as initial therapy in the treatment of CSA. In 
the single unblinded clinical trial, the Remede system did not completely eliminate the CSA. There is no 
documentation that the enrollee has been tried on continuous positive airway pressure (CPAP), bi-level positive 
airway pressure (BiPAP), or supplemental oxygen therapy, which are the standard of treatment for CSA. The 
Remede device is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Remede phrenic nerve stimulator.
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 a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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 a home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the record indicates 
that the enrollee has chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease. The 
record indicates that the enrollee was treated with BiPAP while hospitalized. 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. 
The requested service cannot be 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 a home 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 has required daily oversight for their 
congestive heart failure, lymphedema renal insufficiency, obstructive sleep apnea, and neuropathic pain. You 
say that the enrollee requires daily lab draws and consistently works with therapist with no refusals. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee can get the 
services they need provided safely in other settings. 
 
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 Opdivo in combination with Alimta and carboplatin. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has metastatic 
adenocarcinoma non-small cell lung cancer with KRAS mutation positive. The Food and Drug Administration 
(FDA) has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved 
cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Opdivo in combination with Alimta and carboplatin.
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 will be treated best under the 
oversight of a medical doctor coupled with acute care level interventions and interdisciplinary treatment team 
that drives rehabilitation. You say that the enrollee should be transferred immediately to an LTACH for more 
extended acute care hospitalization based on complexity of their current medical condition. The Plan denied 
your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can get the care 
they need in the current hospital 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional physical therapy (PT) visits 
 
You asked the Plan to pre-approve the additional PT visits. You say that you would like additional visits to be 
approved for coverage for the enrollee. The Plan denied your request. The Plan says additional visits 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 additional PT 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 the enrollee's condition beyond what was approved by the health plan. The 
enrollee has had prior extensive therapy and the documentation does not reveal that they 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. Our reviewer found that 
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 
enrollee's current condition or to prevent or slow further deterioration. The enrollee's functional level does not 
require ongoing skilled therapy. Our physician reviewer also found that the enrollee can transition to an 
independent home 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 the additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 additional physical therapy (PT) visits