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

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found in this case, the record indicates that the enrollee is scheduled for a right total shoulder replacement. The record provided does not indicate that the treating physician has a reasonable 
expectation at the time of admission of a length of stay spanning 2 or more midnights, taking into account 
complex medical factors. The initial day may be spent in observation until it is clearly expected that a second 
midnight would be required, at which time the physician may order inpatient admission. 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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 enrollee requires daily inpatient 
wound care, daily physical assessments, and physical and occupational therapy. The Plan denied your request. 
The Plan says the LTACH service is not medically necessary, and the enrollee's needs at a lower level of care 
such as a skilled nursing facility (SNF). 
 
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 quadriplegic enrollee is currently at a long-term care center with a request for 
LTACH admission to manage stage-four gluteal and sacral decubitus ulcers. The enrollee has a wound 
vacuum-assisted closure (VAC) in place and is COVID-19 positive with a current cough. The enrollee appears 
to only require short-term acute care services, such as debridement and antibiotics, that can safely be provided 
at a short-term acute care hospital (STACH) until more appropriate for discharge back to the long-term care (LTC) center. The enrollee does not require services at the LTACH that would not already be available at the 
STACH.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit for a second opinion to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the physician service. You say that you want to see if a new, aggressive 
treatment plan is available to you. The Plan denied your request. The Plan says there are in-network providers 
available to provide this service. 
 
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 confirmed there are 
network providers available who can provide the services at issue in this appeal. We found no exception that 
would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-
approve an office visit for a second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Proton Beam Radiation Therapy (PBRT). 
 
You asked the Plan to pre-approve the PBRT. You say that the service is medically necessary. The Plan denied 
your request. The Plan says this service is not medically necessary. 
 
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 PBRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over 
other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this 
expensive 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 the PBRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Proton Beam Radiation Therapy (PBRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
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 Botox 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 records show that you have 
overactive bladder with urinary incontinence. The records do not show that you have had an inadequate 
response or are intolerant to an anticholinergic medication, as required by the Medicare criteria. The Botox is 
therefore 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 Botox.
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 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 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 records show that you are receiving wound care at a skilled nursing facility 
(SNF). You do not have any acute care needs and do not require any services that you are not receiving at the 
current setting. The LTACH 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery. 
 
You asked the Plan to pre-approve spine surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documented spinal instability, fracture, or lesion. There is no neurologic deficit on 
exam and no severe spinal stenosis on imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient lift. 
 
You asked the Plan to pre-approve a patient lift. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a patient lift is covered if transfer between bed and a 
chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed confined. 
 
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 patient lift. Our reviewer says that the 
requested patient lift is not medically reasonable and necessary. Our physician reviewer found that although the 
provided medical records report "trouble with mobility due to pain," the provided records do not document that 
the enrollee would be bed confined without the use of a lift, as required by the LCD. 
 
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 patient lift have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a patient lift.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve InSpace Biodegradable Subacromial Spacer (Stryker). 
 
You asked the Plan to pre-approve Stryker. You say that the enrollee is at risk of becoming worse or injuring 
themself. You also say that this is medically necessary. The Plan denied your request. The Plan says the 
requested procedure is not medically necessary. 
 
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 Stryker. Our reviewer says that the 
requested Stryker device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested device is considered experimental as additional research is necessary. Therefore, 
the reviewer found that the requested Stryker device is 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 Stryker have not been met. Therefore, we decided that the Plan does not have to 
pre-approve InSpace Biodegradable Subacromial Spacer (Stryker).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. 
Our reviewer says that the services are medically necessary. Our physician reviewer found based upon review 
the records provided, this patient does meet the criteria for treatment in an acute inpatient mental health 
treatment and could not have been treated in a lesser restrictive setting. He was not showing any suicidal or 
homicidal ideation, however he did have delusional thinking, aggression, poor cooperation and bad 
compliance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric hospital services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 
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 HBOT is covered for specific conditions only.  
 
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 a Wagner stage I 
diabetic non-pressure ulcer that has decreased in size since endovascular treatment. The records do not support 
that the enrollee has a diagnosis for which HBOT is covered. The services are therefore 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 hyperbaric oxygen therapy (HBOT).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says that rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for you. Our physician reviewer found 
that you are a 77-year-old female with past medical history of multiple comorbidities hospitalized with acute 
cerebrovascular accident (CVA) now with functional impairments. In this case, clinical documentation shows 
that patient has complex functional deficits status post CVA and requires ongoing physical therapy, speech 
language therapy and occupational therapy. Evaluating therapists recommend intense therapy in an acute rehab 
setting. Clinical documentation shows that you have active medical comorbidities. Therefore, the complexity of 
the enrollees nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computerized dynamic posturography (92548), and 
VIVE virtual reality advanced vestibular therapy (92700). 
 
You asked the Plan to pre-approve the outpatient services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says he requested services are not medically necessary. 
 
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 outpatient services. Our reviewer 
says that the requested outpatient services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested services are considered experimental. Therefore, the reviewer 
found that the requested computerized dynamic posturography and VIVE virtual reality advanced vestibular 
therapy 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 outpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve computerized dynamic posturography (92548), and VIVE virtual reality advanced 
vestibular therapy (92700).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Gammagard (J1569). 
 
You asked the Plan to pre-approve Gammagard. You say that you were on Rituximab. You say that it was 
destroying your immune system. You say that you are on Rituximab again to put your blood disorder back into 
remission. You also say that you need this drug to keep your immune system as strong as possible and prevent 
you from going back into the hospital. The Plan denied your request. The Plan says that the requested drug is 
not medically necessary. 
 
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 Gammagard. Our reviewer says that the 
requested drug, Gammagard, is medically necessary. Our physician reviewer found the requested drug is useful 
in most people with spontaneous factor VIII:C (FVIII:C) inhibitors. Therefore, the reviewer found that the 
requested drug is medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard have not been met. Therefore, we decided that the Plan has to pre-
approve Gammagard (J1569).  
 
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 home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs the requested device as 
she has severe chronic obstructive pulmonary disease (COPD) and morbid obesity. The Plan denied your 
request. The Plan says the request is not medically necessary because the enrollee has not had their blood levels 
assessed to confirm they have hypercapnia. The Plan says that there is no evidence that the enrollee has tried an 
alternate respiratory assist device and the prescription is written for a bilevel positive airway pressure (BiPAP) 
setting. 
 
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 criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record provided does 
not indicate that the enrollee has failed continuous positive airway pressure (CPAP) or BiPAP. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. 
 
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.