Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee did not have at least 80% relief. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain which radiates bilaterally down her legs with 
numbness and weakness. She has post-laminectomy syndrome. The enrollee had a first set of diagnostic MBBs 
which produced 60% pain relief. The request is for a second set of MBBs. The criteria require 80% pain relief 
from each set of diagnostic MBBs. This was not achieved and therefore another set is not indicated.  The 
request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an iron sucrose injection. 
 
You asked the Plan to pre-approve iron sucrose. You say that you cannot absorb pills and is scared of dying. 
The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the 
information does not show why you cannot take oral iron. 
 
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 iron sucrose. Our reviewer says that 
you do not meet the Medicare criteria for the requested use of iron sucrose. Our physician reviewer found a 
note from your treating provider states you would most likely not tolerate oral iron, but the provided records do 
not document confirmed trial and failure of oral iron supplementation.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of iron sucrose have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an iron sucrose injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), 2-dimensional oral/facial 
photographic images (D0350), and other drugs or medicaments (D9630). 
 
You asked the Plan to pre-approve a crown, 2-dimensional oral/facial photographic images, and other drugs or 
medicaments. You say that the requested services are medically necessary. The Plan denied your request. The 
Plan says the services at issue are not covered benefits. 
 
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 a crown (D2740), 2-dimensional oral/facial 
photographic images (D0350), and other drugs or medicaments (D9630).
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 this is the safest discharge plan and it 
allows the enrollee the highest potential level of function for recovery. The Plan denied your request. The Plan 
says the enrollee's conditions are not sufficiently complex to require LTAC level of care. 
 
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 is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary as the enrollee is not 
doing well at home. The Plan denied your request. The Plan says IRF care is not medically necessary and the 
enrollee's needs can be met in a less intensive setting such as an assisted living facility with home health 
services or at home with home health services. 
 
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 while the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services that an IRF would provide. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet injections. 
 
You asked the Plan to pre-approve the requested services. You say that you are in constant pain. The Plan 
denied your request. The Plan says you did not have documented 80% reduction in your pain level. 
 The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that you have chronic low back pain. You received a facet injection on March 23, 2022, which 
provided a good effect in pain relief. This request is for additional injections. After the first diagnostic facet 
joint procedure, there must be a consistent positive response of at least 80% relief of primary pain. In this case, 
there was no documentation of an 80% reduction in the pain level from the previous facet joint injections. The 
review has determined that the coverage criteria have been 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar facet injections.
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 an IRF will help you a lot and you need to get out of 
the hospital soon. The Plan denied your request. The Plan says the guidelines for coverage 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 does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation.  The enrollees care needs can be met 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 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested 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 the enrollee's medical and rehabilitation needs do not require the intensive 
interdisciplinary approach provided in acute inpatient rehabilitation. The enrollee does not meet the 
requirements for intensive rehabilitation therapy three hours a day and five days a week or 15 hours over seven 
consecutive days. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. 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 is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found based on the 
medical records provided there is no documentation that the enrollee requires the services on an inpatient basis, 
only in a skilled nursing facility setting. Records report the enrollee is participating and benefitting from his 
current treatment and continued care in the rehabilitation facility is appropriate until the enrollee is stable to 
transfer to 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
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 are appealing with supporting records. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information they have about the 
enrollee's condition; the enrollee does not meet all the requirements. 
 
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 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. Our physician reviewer also found that 
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 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. You say that changing medication treatment could hinder the 
enrollee's recovery. The Plan denied your request. The Plan says that there is no support for use of disease 
progression. 
 
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 Keytruda. Our physician reviewer 
found that the enrollee has malignant metastatic melanoma. The requested use of Keytruda is FDA approved 
for the enrollee's diagnosis. Oligometastatic disease is treated with radiation as a standard of care. The use is 
not listed as not indicated, not supported or not recommended in any of the compendia. The documentation 
does support that the requested drug is safe and effective and otherwise reasonable and necessary for this 
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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
pembrolizumab (Keytruda).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve viscosupplementation of the knee using Supartz. 
 You asked the Plan to pre-approve viscosupplementation. You say that the enrollee is in pain. The Plan denied 
your request. The Plan says the enrollee does not meet the coverage criteria for the requested 
viscosupplementation. 
 
The Plan follows Medicare rules. Medicare rules state that viscosupplementation therapy is only covered if 
certain 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 viscosupplementation. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested Supartz viscosupplementation. Our 
physician reviewer found the enrollee has knee pain. The record does not include radiographic documentation 
of osteoarthritis nor a failure of conservative non-pharmacological therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of viscosupplementation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve viscosupplementation of the knee using Supartz.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve skilled nursing facility (SNF) services. You say that you need more skill 
time so that you can return to the level of function and return home. You say that without the physical and 
occupational therapy this will be impossible. The Plan denied your request. The Plan says based on Medicare 
guidelines you do not meet the requirements for approval. 
 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 skilled nursing facility (SNF) services. 
Our reviewer says that you do not meet severity of illness or intensity of service criteria for an inpatient basis in 
a SNF setting. Our physician reviewer found there are no identifiable skilled nursing service needs. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing facility (SNF) services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 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 it is of yours and the other attendings 
opinion that the enrollee cannot be adequately cared for in her current condition at a skilled nursing facility or 
any other lower level of care. You also say that this is where the LTACH level of care would be most 
appropriate for weaning success and clinical improvement. The Plan denied your request. The Plan says based 
on Medicare guidelines, the Long-Term Acute Care Hospital (LTACH) services you and/or your provider are 
requesting do not meet the requirements for approval. 
 
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 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. Our physician reviewer also found that 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no documentation of a skilled nursing need. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 requested services. Our physician 
reviewer found that in this case, the documentation does support that the enrollee requires additional skilled 
nursing services to provide treatment in order to improve her condition, perform a maintenance program to 
maintain her condition or prevent deterioration. She has been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. Therefore, the requested home health services 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing services.