Persius/hicric huggingface dataset:
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 do better at a rehabilitation 
facility because the extra help is needed to help with walking and to remain independent. The Plan denied your 
request. The Plan says SNF care is not medically necessary and therapy needs can be met at a lower level of 
care. 
 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 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 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: 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. 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 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 the enrollee was admitted for gangrene, osteomyelitis, and a below the knee 
amputation. Medical problems are stable.  
 There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation 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 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 the enrollee requires very close nursing care and 
physical therapy to work on increasing strength. You say that the enrollee was independent in their mobility 
prior using a rollator walker and completed activities of daily living without assist. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary, and the enrollee can receive the care they 
need 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint injections with imaging 
guidance. 
 
You asked the Plan to pre-approve paravertebral facet joint injections with imaging guidance. You say that 
these injections are medically necessary. The Plan denied your request. The Plan says these injections are 
investigational and therefore non-covered. 
 
The Plan follows Medicare rules. Medicare rules say that paravertebral facet injections are potentially 
coverable when medically necessary and other 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 paravertebral facet joint injections with 
imaging guidance. Our reviewer says that the requested facet joint injections are not medically necessary. Our 
physician reviewer found this is considered experimental/investigational because of the wide variation in 
efficacy reported in the peer reviewed literature.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of paravertebral facet joint injections with imaging guidance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint injections with 
imaging guidance.
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 this device is medically necessary for the 
patient. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found this patient has chronic 
obstructive pulmonary disease, severe obesity with obesity-hypoventilation syndrome, and aortic stenosis. The 
patient was hospitalized with pneumonia recently, and arterial blood gases in the hospital were consistent with 
acute on chronic hypercarbic respiratory failure.  Progress notes indicate the patient had either bi-level positive 
airway pressure (BiPAP) or a ventilator at home previously.  One note says the BiPAP broke, the other says patient was noncompliant with the ventilator and it was removed. This patient may benefit from BiPAP with 
average volume assisted pressure support (AVAPS) during sleep as an outpatient. 
 
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 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 admission to an inpatient psychiatric facility. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no medical problems reported or severe side effects from medications. 
 
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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found that the health plans denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require 
inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and 
does not have auditory or visual hallucinations. It did not appear that active treatment was taking place beyond 
the date in question. It did not appear that the services were reasonably expected to improve the patients 
condition or for the purpose of diagnosis beyond the date in question. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an inpatient psychiatric facility.
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 does not meet 
criteria. 
 
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 was admitted for surgical management of a pathologic hip fracture. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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 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 does not meet 
criteria. 
 
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 cannot tolerate, adequately participate in or reasonably benefit from 
intensive therapy. He has limited capacity to cooperate with therapy. He is deconditioned and does not require 
frequent physiatry oversight or have complex rehabilitation needs. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Paclitaxel, and Carboplatin. 
 
You asked the Plan to pre-approve Keytruda, Paclitaxel, and Carboplatin. You say that the requested drugs are 
medically necessary. The Plan denied your request. The Plan says the enrollee was found to have local 
recurrence 18 months after prior excision and chemoradiation. The Plan says that the enrollee now has had re-
excision. The Plan says that the documentation now indicates that the enrollee has low PDL1 positive disease. 
The Plan says that there is no support for the requested regimen in this clinical setting. 
 
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, Paclitaxel, and Carboplatin. 
Our reviewer says that Keytruda, Paclitaxel, and Carboplatin are not medically necessary for this patient. Our 
physician reviewer found there is only data in the drug compendia for the use of a single agent. These three 
drugs together are not FDA-approved for the patient's condition, and the use of this drug combination is not 
supported or recommended in any of the compendia.  
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, Paclitaxel, and Carboplatin have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Keytruda, Paclitaxel, and Carboplatin.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sedation for a therapeutic injection (99152). 
 
You asked the Plan to pre-approve sedation services. You say that you requested a pain relief injection with 
sedation. You say that the sedation was denied. You say that you did not have the procedure done because you 
cannot do the procedure without the sedation. You also say that you have a history of anxiety. The Plan denied 
your request. The Plan says the provided documentation does not support the medical necessity of the 
requested sedation. 
 
The Plan follows Medicare rules. Medicare rules say that use of Moderate or Deep Sedation, General 
Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for epidural 
steroid injection procedures and therefore not considered medically reasonable and 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 sedation services. Our reviewer says 
that the requested sedation is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate why oral anxiolytics would not suffice for this anxiety. The reviewer found 
that the documentation does not support exceptional or unique conditions that would require this injection of 
anesthesia. Therefore, the reviewer found that the requested sedation 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 sedation services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sedation for a therapeutic injection (99152).
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 are unable to ambulate on your own very well 
and have speech difficulties. The Plan denied your request. The Plan says admission to the IRF was denied as it 
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 you were admitted for a stroke in 2017 and knee replacement in 2019. You have 
difficulty with walking. Medical problems are stable.  There are no complex nursing or rehabilitation needs. While you have a need for physical or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral surgery (21046, 41874) performed by a dentist on 
December 21, 2020. 
 
You asked the Plan to pay for oral surgery. You say that this should be covered. The Plan denied your request. 
The Plan says this is not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for oral surgery (21046, 41874) 
performed by a dentist on December 21, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography (95811) and sleep latency testing 
(95805). 
 
You asked the Plan to pre-approve polysomnography and sleep latency testing. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules say that type I polysomnography (PSG) is covered when used 
to aid the diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms 
indicative of OSA if performed attended in a sleep lab facility. 
 
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 polysomnography and sleep latency 
testing. Our reviewer says that the requested testing is not medically necessary. Our physician reviewer found 
the record shows that the enrollee has a longstanding history of insomnia, along with multiple medical and 
psychiatric problems. The enrollee reports a previous sleep study and was told she did not need a continuous 
positive airway pressure device. The problem is described as difficulty falling and staying asleep, but there is 
no mention of snoring, observed apneas, or morning headaches.  There is no mention of symptoms consistent 
with parasomnias or narcolepsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of polysomnography and sleep latency testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve polysomnography (95811) and sleep latency testing 
(95805).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation of portable x-ray equipment, set-up of portable 
x-ray equipment, and a skull x-ray, provided on July 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for transportation of portable x-ray equipment, set-up of portable x-ray equipment, 
and a skull x-ray. You say that CPT 70250 was required to further diagnose the patient and provide the 
appropriate care. You also say CPT code Q0092, set-up portable x-ray equipment, and CPT code 
R0070/R0075, transportation of portable x-ray equipment and personnel to home or nursing home, per trip to 
facility or location, were needed in order to assess, evaluate, diagnose, treat and manage the member's health 
conditions. You are appealing with medical records supporting medical necessity. The Plan denied your 
request. The Plan says the enrollee must receive care from a network provider. 
 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for transportation of portable x-ray equipment, set-up 
of portable x-ray equipment, and a skull x-ray, provided on July 3, 2022, by an out-of-network (OON) 
provider.