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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 and should only require short-term additional 
acute care services that can be safely administered at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Transfer to LTACH 
is not medically necessary as it would not be clinically advantageous to completing care at the current facility 
until appropriate for a lower 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF services. 
 
You asked the Plan to pre-approve continuation of SNF services. You say that since being back at the skilled 
rehabilitation facility, the enrollee has had multiple falls in two weeks due to weakness, resulting in a broken 
hip. You say that prior to the fall, the enrollee was able to perform activities of daily living and ambulate 
independently.  You say she is currently a moderate assist with walking, transfers toileting, and dressing but is still in need of 
rehabilitation to get her back to her prior level of function so she can be safe when returning home. The Plan 
denied your request. The Plan says based on Medicare guidelines, your request for approval of continued 
admission in skilled nursing facility does 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 continuation of SNF services. Our 
reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based 
on the documentation provided, the enrollee no longer qualifies for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is ambulating more than 100 feet. Daily skilled services are not required to establish a maintenance program or 
to prevent deterioration of the enrollees condition. The enrollees care needs are custodial and, as a practical 
matter, can be provided at a lower level of care (ex. home with services, assisted living, long term 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 continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of SNF services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for SNF admission. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the member does not have any 
parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without 
any acute exacerbations of chronic medical problems.  Her physical function is at or near her baseline and she 
can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Skilled Nursing Facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested services are experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to show the 
safety and efficacy of the procedure. 
 
 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
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 you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manipulation procedures on the spine with anesthesia. 
 
You asked the Plan to pre-approve manipulation procedures on the spine with anesthesia. The Plan denied your 
request. The Plan says spinal manipulation with anesthesia 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 manipulation procedures on the spine 
with anesthesia. Our reviewer says that the requested manipulation procedures on the spine with anesthesia are 
not considered medically reasonable and necessary in this case. Our physician reviewer found that the record 
indicates that the enrollee has been receiving chiropractic care for back pain. The record provided does not 
support the medical necessity and reasonableness, as defined by Medicare rules, of anesthetic services in the 
enrollee's specific clinical circumstances. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. The requested service is not recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of manipulation procedures on the spine with anesthesia have not been met. 
Therefore, we decided that the Plan does not have to pre-approve manipulation procedures on the spine with 
anesthesia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional chiropractic therapy visits. 
 
You asked the Plan to pre-approve the chiropractic visits. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support 
that the enrollee meets the medically necessary criteria. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic visits Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the record indicates that the enrollee has thoracic subluxation, and sacral 
and pelvic dysfunction.  The record provided is insufficient to determine the treatment provided and whether it 
was administered for spinal subluxation. 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 chiropractic visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 2 additional chiropractic therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that you would like reconsideration because the 
SNF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for SNF admission. 
 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee is off IV antibiotics, has no 
complex wound care. His PEG was discontinued. The enrollee's functional level does not require  skilled 
therapy services in a SNF with  the specialized skill, knowledge and judgment of a qualified therapist required 
to safely and effectively provide medically necessary and reasonable treatment. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Skilled Nursing Facility (SNF) admission.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute 
exacerbations of chronic medical problems. His physical function is at or near his baseline and he can receive 
services at a lower 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair van transportation to an appointment. 
 
You asked the Plan to pre-approve the wheelchair van transportation. You say that the enrollee has no other 
way to get the surgery due to her inability to walk, and she needs to have a wheelchair van to get into the 
wheelchair. You also say that this is medically necessary for the enrollee's surgery and medical appointment. 
The Plan denied your request. The Plan says this service is not covered by Medicare or offered as a 
supplemental benefit by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
 
 
 
 The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair van transportation to an appointment.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclobenzaprine 5 mg tablet. 
 
You asked the Plan to pre-approve Cyclobenzaprine. You say that this drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs.  The self-administered drugs requested here are not among the types which are covered by Medicare Part B. 
Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine 5 mg tablet.  
 
Benefits for Cyclobenzaprine 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
met criteria for SNF admission. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require transfer 
to a SNF for skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". 
As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled 
nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for treatment with Dopamine (J1265) provided on October 7 to October 
14, 2021. 
 
You asked the Plan to pay for Dopamine. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because the 
provided records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 83 units of CPT code J1265 are supported in the medical record. Based on this information, we 
decided that Medicare rules for coverage of Dopamine have been met. Therefore, we decided that the Plan has 
to pay for treatment with Dopamine (J1265) provided on October 7 to October 14, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this has not been shown to be safe and effective in long term 
studies and there is a lack of evidence to support that interspinous spacer devices are as safe and effective as 
the gold standard of decompression. 
 
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 requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epoetin alfs-epbx. 
 
You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says the 
enrollee's hemoglobin is within normal limits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the requested drug. Our physician 
reviewer found that in this case, the record indicates the enrollee has metastatic squamous cell carcinoma of the 
tongue. The record indicates that the enroll has a hemoglobin of 12.5 g/dl prior to the initiation of treatment. 
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 requested drug have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Epoetin alfs-epbx.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
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 PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a new diagnosis of 
prostate cancer with possible rib metastases. An axumin PET/CT is requested. This is approved for men 
suspected of prostate cancer recurrence with rising prostate specific antigen (PSA); it is not approved for initial 
diagnosis. The services 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.