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 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 showed excellent progress over 3 days with a low level of therapy. She 
was deconditioned post-acute stay and had modest rehabilitation needs at the start of therapy. Her progress is 
consistent with her deconditioned state and the quality of the medical care which restored her cardiac status. 
She by her own performance does not require intensive or complex rehabilitation services. She has no medical 
condition requiring complex medical rehabilitation services. She does not require frequent physiatry oversight. 
Congestive heart failure is a chronic condition routinely managed at the outpatient level. 
 
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, Carboplatin, and Pemetrexed. 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, and Pemetrexed. 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 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 Keytruda, Carboplatin, and 
Pemetrexed. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
combination of carboplatin, pemetrexed, and pembrolizumab is not a standard of care. Pembrolizumab is 
reserved for recurrent disease for head and neck cancer and for tumor mutational burden (TMB) high tumors. 
The service is 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 Keytruda, Carboplatin, and Pemetrexed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Keytruda, Carboplatin, and Pemetrexed.
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 LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the patient is a 61-year-old male who was admitted to the acute care hospital 
with pneumonia, sepsis, and acute respiratory failure requiring intravenous antibiotics and mechanical 
ventilation support, complicated by urinary tract infection, status epilepticus. Recent notes describe the patient 
is now tolerating high flow oxygen via trach mask and has passed the swallow study. The patient appears to be 
more stable and improving and should only require short-term additional acute care services that can be safely 
administered at the current facility until more appropriate for a lower level of care. The patient does not require 
services at the LTACH that are not already available at the current facility. Transfer to 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cardiac rehabilitation provided from 
January 10, 2022, to February 21, 2022. 
 
You asked the Plan to waive the coinsurance for cardiac rehab. You say that since your doctor recommended 
this you thought it would be covered. The Plan denied your request. The Plan says the coinsurance applied is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 10% 
coinsurance for each Medicare-covered cardiac rehabilitative visit.  
 
 
 
 
 You have been asked to pay $221.55 which is 10% of the allowed amount for cardiac rehab. The allowed 
amount is $2,216.13 (10% x $2,216,13 = $221.55). Cardiac rehab falls within the Cardiac Rehabilitation 
Services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for cardiac rehabilitation 
provided from January 10, 2022, to February 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
February 22, 2022, to March 2, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you paid $195 copayment 
at the hospital, and you dont understand why you must pay more. The Plan denied your request. The Plan says 
the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $195 
copayment per day for days 1 through 5. 
 
You have been asked to pay $975 (5 days x $195) copayment for inpatient hospital stay. Inpatient hospital stay 
falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for inpatient hospital stay provided from February 22, 2022, to March 2, 2022.
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 reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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. The enrollee 
does 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 this 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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical information received states the member recently experienced a 
Transient Ischemic Attack (TIA) -a temporary blockage of blood to the brain, with residual physical deterioration and physical deconditioning. In this case, the documentation indicates that 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. The enrollee does 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 this 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the patient is a 56-year-old female who was admitted to the acute care hospital 
with acute respiratory failure and pneumonia requiring mechanical ventilation and antibiotics and tube feeds. 
The patient appears to be more stable and improving and should only require short-term additional acute care 
services that can be safely administered at the current facility until more appropriate for a lower level of care. 
The patient does not require services at the LTACH that are not already available at the current facility. 
Transfer to 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 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 functional impairment is not likely to change. Your stroke was 9 months ago, and 
you have not regained function on the left side of your body. There is no evidence-based standard supporting 
an intensive inpatient rehabilitation program to improve function 9 months post stroke. You have no medical 
issues requiring inpatient care while you undergo rehabilitation and there is no evidence indicating intensive 
rehabilitation is reasonable or necessary for a likely unchanging neurological impairment 9 months post-acute 
event. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary at 
this time for the enrollee's condition. The Plan denied your request. The Plan says transfer to a SNF from an 
inpatient rehabilitation facility is not medically reasonable and necessary.  
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 medically reasonable and necessary. Our physician reviewer found that based on the 
documentation provided, the enrollee does not have documented skilled nursing needs. Furthermore, the 
enrollee does not have documented skilled therapy needs. In this case, the enrollee is ambulating more than 100 
feet and tending to activities of daily living with minimal supervision.  Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of the enrollees condition.  The enrollees care 
needs, custodial and intermittent, can, as a practical matter, be provided 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 admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) of the whole body (78816). 
 
You asked the Plan to pre-approve the imaging services requested. You say that this imaging is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the imaging services requested. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee has a diagnosis of polymyalgia rheumatica (PMR), as well 
as hypertension, and dyslipidemia. The treating specialist is recommending PET/CT imaging services to 
evaluate for inflammation and active polymyalgia rheumatica to direct the plan of care. In this case, it has not 
been established in the medical literature that PET/CT imaging is of prognostic or therapeutic consequence in 
patients with PMR.  
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 imaging services requested have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) of the whole body (78816).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presbyopia correction function of intraocular lens (P-C 
IOL) and self-administered drugs provided on December 22, 2021. 
 
You asked the Plan to pay for the P-C IOL and self-administered drugs. You say that you believe that you are 
being overcharged beyond the copayment. The Plan denied your request. The Plan says this claim has denied 
correctly, and no additional payment will be made. 
 The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL. The rules say that Medicare Part B generally does not pay for self-administered drugs. 
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. In addition, 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 pay for the presbyopia 
correction function of intraocular lens (P-C IOL) and self-administered drugs provided on December 22, 2021.  
 
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves. 
 
You asked the Plan to pre-approve RFA of the genicular nerves. You say that you are experiencing knee pain 
level 8 during the day with movement. With medication, your pain level is at a 6. You say that Oxycodone and 
Gabapentin both make you nauseous and you do not like to take them. The Plan denied your request. The Plan 
says medical studies have not proven that this requested service is helpful for the treatment of the enrollee's 
health problem. 
 
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 RFA of the genicular nerves. Our 
reviewer says that RFA of the genicular nerves is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has osteoarthritis of the Left knee. She takes Diclofenac, 
gabapentin, oxycodone and naproxen. She has had a Duralane injection. RFA of the genicular nerves is still 
being investigated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA of the genicular nerves have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablations (RFAs). 
 
You asked the Plan to pre-approve repeat RFAs. 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 frequency limitation: For each covered spinal region 
no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 
 
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 repeat RFAs. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found this request exceeds utilization limits and is 
therefore deemed, not medically 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 repeat RFAs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat radiofrequency ablations (RFAs).