Persius/hicric huggingface dataset:
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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with bacteremia, sepsis, and a chronic sacral ulcer requiring intravenous (IV) 
antibiotics and basic wound care. She also required dialysis for end-stage renal disease. The recent notes state 
she is respond to treatment. She is stable and improving and should only require short-term additional acute 
care services that can be safely administered at the current facility. She does not require services at the LTACH 
that are not already available at the current facility. There are no services at the LTACH that she requires that 
are not already available and covered at the current facility. Transfer to LTACH 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic electrocardiogram. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no concern for a heart rhythm. 
 
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 at issue is the medical necessity of a repeat transthoracic electrocardiogram (TTE), in the 
absence of any apparent significant change in the patients clinical condition.  Clinical guidelines do not support repeating a TTE with no intervening change in clinical status or physical 
findings. In summary, there is no supportive evidence for the medical necessity of repeat TTE in this this 
enrollees 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transthoracic electrocardiogram.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided from September 15, 2021, to September 17, 
2021. 
 
You asked the Plan to pay for the inpatient stay. You say that the inpatient stay was medically necessary at the 
acute level of care. The Plan denied your request. The Plan says that the inpatient stay was not medically 
necessary. 
 
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 pay for the inpatient stay. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found at the time of inpatient admission the admitting physician reasonably expected that the patient's 
necessary hospital care (including earlier emergency department and/or observation care) would span two 
midnights. 
 
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 inpatient stay have been met. Therefore, we decided that the Plan has to pay 
for the inpatient stay provided from September 15, 2021, to September 17, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genomic Unity Exome Analysis testing. 
 
You asked the Plan to pre-approve Genomic Unity Exome Analysis. You say that this testing is medically 
necessary to arrive at a unifying diagnosis and avoid continued evaluations and tests. The Plan denied your 
request. The Plan says the denial of authorization for this testing is correct, because this testing is unlikely to 
impact therapeutic decision-making in the clinical management of an enrollee and will be denied automatically. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers molecular diagnostic tests that 
have been approved by the molecular diagnostics (MolDX) contractor.  
 
We looked at the file and Medicare rules. Genomic Unity Exome Analysis testing has not been approved by the 
MolDX contractor, so is not covered by Medicare at this time. Based on this information, we decided that 
Medicare rules for coverage of Genomic Unity Exome Analysis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Genomic Unity Exome Analysis testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six office consultations to be provided by an out-of-
network (OON) neurosurgeon. 
 
You asked the Plan to pre-approve the OON neurosurgery services. You say that the requested provider has 
experience dealing with the patient's shunt. You believe it would be best for her to return to her previous 
neurosurgeon. The Plan denied your request. The Plan says Plan neurosurgeons are available to treat the 
patient. 
 
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 network providers 
available who can provide the items/services at issue in this appeal. The patient is not in an active course of 
treatment with the requested provider. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve six office consultations to be 
provided by an out-of-network (OON) neurosurgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for worsening sacral pressure ulcer, bacteremia, and COPD exacerbation and their medical problems 
are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the patient has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program.  
There is not a reasonable expectation that this patient 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 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for surgical repair of a hip fracture after a fall. The complexity of her nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She is now medically stable with no complex nursing or rehabilitation needs. She does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While she has a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive rehabilitation program. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (CPT code 0266T). 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that the service is necessary. The Plan 
denied your request. The Plan says the Barostim Neo has not been shown to improve outcomes in cases like the 
enrollees. 
 
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 Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at this time the Barostim Neo system would not be considered medically reasonable 
and necessary in this enrollees 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 Barostim Neo 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Barostim Neo 
device (CPT code 0266T).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that there is no way that you can go home at this time. 
You say that you do not have anyone to care for you and you live alone. You say that you are wheelchair bound 
and are on oxygen 24/7. You say that SNF care is needed until you are independent and have regained your 
strength. The Plan denied your request. The Plan says that SNF care is not reasonable and necessary for the 
treatment of the enrollee's condition. The Plan says that the enrollee's 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 
criteria for coverage have been met. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs, though intermittent lab draws for sodium monitoring is reasonable.  The enrollee does 
have documented skilled therapy needs.  The enrollee is functioning below his baseline.  Documentation does 
not yet establish that the enrollee has reached a new, lower, level of function.  Daily skilled services are 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
 
 
 
 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: 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 you may lose your ability to regain function and 
independence if you are not able to go to a SNF to regain your strength with rehabilitation services. The Plan 
denied your request. The Plan says your request does not show you have skilled nursing or therapy needs that 
need to be provided on a daily basis as an inpatient only status. The Plan states the services you require can 
safely be received at a different setting, for example, home with home health, in residential care, or home with 
close follow-up with your doctor. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services 
with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence 
of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does 
not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist 
to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter, you do not require the necessary services 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 SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mavyret tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that this is needed by the enrollee. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not 
covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 
benefits. 
 
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 Mavyret tablets.  
 Benefits for self-administered drug 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF services are not medically necessary. You are medically stable with no 
evidence of need for supervision by a rehab physician or need for acute rehab nursing 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
respiratory failure, atrial fibrillation, and congestive heart failure. Your medical problems are stable. There are 
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 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: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) colonography. 
 
You asked the Plan to pre-approve CT colonography. You say that this service is medical necessary for the 
evaluation of the enrollee's abnormal weight loss and past history of tortuous sigmoid colon. A virtual test is 
needed to reduce risk of perforation. The Plan denied your request. The Plan says that there is no clinical 
information documenting medical necessity of CT colonography 
 
The Plan follows Medicare rules. Medicare rules say that CT colonography is indicated when the patient's 
physician determines from an evaluation of the patient that optical colonoscopy cannot be safely attempted. 
 
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 CT colonography. Our reviewer says 
that the requested CT colonography is medically necessary. Our physician reviewer found this patient has 
unintentional weight loss and a history of atyical colonic nodularity in follow-up to which colonic evaluation 
has been advised. The patient's doctor has attested that the patient's last colonoscopy was complicated by 
sigmoid tortuosity such that subsequent colon exams unduly increase her risk of perforation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT colonography have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomography (CT) colonography.  
 
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.