Persius/hicric huggingface dataset:
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 enrollee needs to be assessed both medically and 
functionally regarding their premorbid functional capacity to determine whether they can benefit from a 
rehabilitation level of care offered by mentioned facility. The Plan denied your request. The Plan says the 
services the enrollee needs can be provided safely in another setting such as a skilled nursing facility, home 
with home health services or home with outpatient therapy. 
 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 treatment by multiple therapies. 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 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. The Plan denied your request. The Plan says you do not require a 
multidisciplinary approach to daily therapy. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for lower extremity weakness. Your medical problems are stable. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
in an intensive rehabilitation therapy 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet block injection. 
 
You asked the Plan to pre-approve a facet block injection. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet specific criteria. 
 
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 facet block injection. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the request exceeds utilization 
limits and therefore, is deemed not 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 a facet block injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a facet block injection.
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 member needs therapy at the skilled nursing 
level for a safe discharge home. The Plan denied your request. The Plan says the SNF services requested 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing 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 skilled nursing facility (SNF) care.
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 enrollee needs care to achieve a safe and 
sustainable discharge. The Plan denied your request. The Plan says the enrollee's rehabilitation needs are not 
complex. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for surgical management of a subdural hematoma. The 
enrollee was transferred to skilled nursing, then discharged home. The enrollees medical problems are stable. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The complexity of the enrollees nursing, medical and 
rehabilitation needs does not 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 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 genicular nerve radiofrequency ablation (RFA). 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that you have left knee osteoarthritis. 
The requested genicular nerve RFA is not considered safe and effective for the treatment of knee osteoarthritis. 
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 genicular nerve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA). 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has bilateral knee 
osteoarthritis. He had a bilateral genicular nerve block on February 21, 2023 that provided 80 percent pain 
relief for one to two days. The requested genicular nerve RFA is considered experimental/investigational in 
nature and is the subject of ongoing clinical trials. The services are therefore not reasonable or medically 
necessary at this time.  
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 genicular nerve radiofrequency ablation (RFA).
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 you feel the enrollee will need additional PT after 
discharge from the rehab facility. The Plan denied your request. The Plan says the SNF services you are 
requesting 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing 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 skilled nursing facility (SNF) 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 member's current medical condition 
requires an LTACH admission. The Plan denied your request. The Plan says the LTACH services requested 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 the enrollee appears to be improving with current treatment and requires short-term 
additional acute care services that can safely be provided at the current facility. The enrollee does not require 
services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary for the 
enrollee to receive the care needed to regain maximum function and continue their multidisciplinary approach 
to care. The Plan denied your request. The Plan says the enrollee can continue to receive their current acute 
care needs at the current acute care setting which is already approved by the health plan. 
 
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 acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. 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. 
 
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 intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the requested services. You say that IMRT results in more conformal target 
coverage. The Plan denied your request. The Plan says there is no evidence IMRT is needed or helpful for the 
enrollee's condition. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being offered palliative IMRT for a pelvic metastasis. IMRT for bone or 
metastases is uncommonly needed for palliative treatment. There is no dosimetric rationale for IMRT or 
explanation for why this enrollee requires palliative treatment. IMRT for palliative treatment would not be 
furnished in accordance with accepted standards of medical practice. Therefore, the request is not medicaly 
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 intensity modulated radiation therapy (IMRT).
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. The Plan denied your request. The Plan says you do not require a 
complex multidisciplinary approach to daily therapy. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for a below the knee amputation. Your medical problems are 
stable. You do not require treatment by multiple therapies in 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left ventricular assist device (LVAD). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the submitted documentation does not show an ejection fraction of less than or equal to 
25% or dependence on ionotropes. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of LVAD placement in this patient's 
management. The patients LV ejection fraction is above 25% and the patient does not have NYHA Class IV 
heart failure. As such, guidelines for placement of an LVAD in this setting are not met. In summary, there is 
insufficient documentation to support the medical necessity for LVAD placement in this patients clinical 
management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a left ventricular assist device (LVAD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiotherapy. 
 
You asked the Plan to pre-approve proton beam radiotherapy. You say that the requested proton beam 
radiotherapy is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested proton beam radiotherapy. 
 
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 proton beam radiotherapy. Our 
reviewer says that the enrollee does not meet criteria for the requested proton beam radiotherapy. Our physician 
reviewer found there is insufficient prospective, long-term clinical data available to determine whether or not 
proton beam radiation therapy (PBT) for prostate cancer is superior, inferior, or equivalent to external beam 
radiation therapy, intensity modulated radiotherapy (IMRT), or brachytherapy with regards to safety and 
efficacy. Recent data shows no significant differences in late (years one, two, and three) patient-reported 
toxicity outcomes between proton beam therapy and IMRT. The most recent American Urological Association 
(AUA) and National Comprehensive Cancer Network (NCCN) guidelines state that PBT offers no clinical 
advantage over other forms of definitive treatment. According to NCCN and ASTRO guidelines proton beam 
therapy may be offered to individuals enrolled in an Institutional Review Board (IRB) approved prospective 
clinical trial or multi-institutional registry that adheres to Medicare requirements for coverage with evidence 
development (CED). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiotherapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton beam radiotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information received did not support the medical necessity for this service. 
 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has obstructive sleep apnea. The record provided 
does not document objective evidence of adherence to use of the PAP device, reviewed by the treating 
practitioner. The elements of the coverage criteria are not satisfied. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued use of a continuous positive airway pressure (CPAP) device.