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 you were independent prior to a fall and 
rehabilitation will give you many hours of physical therapy to get back to baseline. The Plan denied your 
request. The Plan says after careful review of the details contained in the case file, we have determined that 
your request is not medically necessary at this time. 
 
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 you do not have functional impairments. Evaluating therapies along with 
physical medicine and rehabilitation consult note recommends intense therapy and that you would be able to 
tolerate fifteen hours of therapy per week. A syncopal event is not an IRF compliant diagnosis and there are no 
specific active comorbidities listed as requiring continued close medical monitoring 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were in excellent physical health before injury 
and provider expects you to be able to successfully complete acute rehab and can make recovery if they get 
intense physical therapy. The Plan denied your request. The Plan says medical necessity has not been met and 
care can be provided at a lower level. 
 
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: Favorable

 
We decided that the Plan has to pre-approve the toe amputation (CPT code 28820). 
 
You asked the Plan to pre-approve the toe amputation. You say that amputation of the second left toe is needed 
because of peripheral artery disease which is causing swelling and complications. The Plan denied your 
request. The Plan says that this situation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 toe amputation. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found given that the bunion deformity is not painful, it is certainly reasonable for the painful 
hammertoe contracture to be removed as a singular procedure. Therefore, the requested amputation of the 
painful second digit left side is medically reasonable and 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 toe amputation have been met. Therefore, we decided that the Plan has to 
pre-approve the toe amputation (CPT code 28820).  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you prefer to admit to IRF because you were 
independent before your hospitalization, and you want to return to being independent. You also say that you are 
eager to participate in the three hours of aggressive rehabilitation that an IRF will offer you. The Plan denied 
your request. The Plan says based on Medicare guidelines, the IRF services being requested do not meet the 
requirements for approval. 
 
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 the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient's medical status does not require intensive physician and nursing oversight 
in an IRF. Our physician reviewer also found that while the patient may benefit from additional multiple 
therapies, including physical and occupational therapy, the documentation does not reveal that the patient 
requires this therapy on an intensive IRF level. 
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the records show that it is not reasonable to expect that the enrollee will be 
able to safely participate in, or fully benefit from, the intensity of services of an IRF. The services they need 
can be 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 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: 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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested 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 the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have a broken pelvis bone and cannot be 
released home because you do not have a walker or wheelchair to get around. The Plan denied your request. 
The Plan says your current care needs do meet Medicare criteria for admission. The therapy you need can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
admission to a LTACH. The Plan denied your request. The Plan says we will continue to cover medically 
necessary acute and critical care at the current facility until your condition is stable for transfer to an alternate 
level of care, such as a skilled nursing facility, or until the clinical circumstances change such that LTACH 
may be reconsidered. 
 
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 were admitted to the acute on September 12, 2022, due to recent falls and right 
lower extremity weakness. The MRI of the brain showed multiple chronic cortical infarctions and the work up 
was remarkable for pulmonary nodular amyloidosis. There is no documentation provided indicating medical 
necessity for admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You 
do not require services at the LTACH that are not available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for omalizumab injections and office visits provided on 
December 13, 2021, to April 5, 2022 
 
You asked the Plan to pay for omalizumab injections and office visits. You say that you were never charged 
when receiving the same injections in the past, therefore you should not be responsible for these charges. The 
Plan denied your request. The Plan says coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance and $45 copayment for Medicare Part B prescription drugs and Physician/Practitioner services, 
including doctors office visit.  
  You have been asked to pay $1,889.44, for the omalizumab injections and office visits.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
December 13, 2021 Specialist visit $60.47 $45 $45 
December 13, 2022 Administration of 
drug 
$2,147.08 20% $429.42 
January 10, 2022 Specialist visit $60.49 $45 $45 
January 10, 2022 Administration of 
drug 
$2,137.90 20% $427.58 
February 23, 2022 Specialist visit $60.49 $45 $45 
February 23, 2022 Administration of 
drug 
$2,137.90 20% $427.58 
April 5, 2022 Specialist visit $60.49 $45 $45 
April 5, 2022 Administration of 
drug 
$2,124.28 20% $424.86 
TOTAL:    $1,889.44 
 
Omalizumab injections and office visits fall within the Medicare Part B Prescription Drugs and 
Physician/Practitioner Services, including Doctors Office Visit benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to pay for omalizumab injections and office visits provided on December 13, 2021, to April 5, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a testosterone cypionate 200mg/ml injection. 
 
You asked the Plan to pre-approve a testosterone cypionate 200mg/ml injection. You say that the member has 
been stable on current medication since 2017, and current dosage since 2019. You also say that this member 
takes the medication for testosterone deficiency. You also say that this medication is medically necessary. The 
Plan denied your request. The Plan says this drug for this use is covered under the Medicare Part D pharmacy 
benefit. The Plan also says that this drug is not covered under the Medicare Part B or the outpatient office 
benefit.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a testosterone cypionate 
200mg/ml injection.  
 
Benefits for a testosterone cypionate 200mg/ml injection may be available under Medicare Part D. Contact the 
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 have fallen four times in the last month, and she 
did not like the skilled nursing facility she was admitted to. The Plan denied your request. The Plan says the 
criteria for IRF services 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 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 
urinary tract infection, congestive heart failure, and COVID 19 infection. Your medical problems are stable, 
and there are no 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 you 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET with CT scan. You say that the requested PET with CT scan is 
medically necessary. The Plan denied your request. The Plan says the requested PET with CT scan is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET with CT scan. Our reviewer says 
that the requested PET with CT scan is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a sclerotic lesion. The record does not indicate that there is cancer. Therefore, the 
national coverage determination does not apply. The medical record provided does not document the medical 
necessity of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. The requested service is not 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 PET with CT scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) scan (78815).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from physical and 
occupational therapy in this setting to assist with regaining baseline functional ability. The Plan denied your 
request. The Plan says based on Medicare guidelines and the information we have about the enrollee's 
condition they 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 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 the enrollee is ambulating more than one hundred feet. 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. Our reviewer also found that 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 SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from continued SNF 
services. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF care and can 
be treated at an alternative level of care such as discharge home with home health care services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.