Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show any conditions that are likely to require 25 more 
days of hospital care with daily physician monitoring or specialized nursing services only available in a 
hospital setting. 
 
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 was admitted with congestive heart failure exacerbation and acute 
hypoxic and hypercapnic respiratory failure. The record indicates that the enrollee is improving but still 
requires ongoing acute care services. The enrollee continues to receive acute care services and these have not 
been denied. 
 The medical record does not indicate that the enrollee requires services that she is not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Renflexis. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this drug should not be taken in conjunction with Stelara, due to the increased 
change of life-threatening infections. 
 
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 drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the record indicates that 
you have a diagnosis of moderate-to-severe Crohns Disease.  The Food and Drug Administration has stated 
that the requested drug is indicated for your condition. The record indicates that you are receiving Stelara for 
psoriasis. Although DrugDex, a Medicare approved compendium states that concomitant use of these two 
agents is not recommended, there is no prohibition to concomitant use. The record provided establishes the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service in this clinical 
situation. The elements of the coverage criteria are 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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Renflexis.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visits (99345) provided on September 14, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home visits. You say that you would like reconsideration because these 
services were not rendered. The Plan denied your request. The Plan says the services at issue were provided 
out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal.  The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visits 
(99345) provided on September 14, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says it is not safe to leave the hospital at this time. 
 
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 you were admitted with hypoxic respiratory failure due to COVID-19 infection.  The 
record indicates that you require increasing oxygen support and acute care services. You continue to receive 
acute care services and these have not been denied. The medical record does not indicate that you require 
services that you are not currently receiving but that would be available at the LTACH facility. The elements of 
the coverage rules 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 LTACH services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care 
hospital (LTACH).
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 is unsafe to return home due to limited 
functional mobility and strength and will need to continue medical care and skilled therapy services at inpatient 
rehab to regain her independence and return home safely. The Plan denied your request. The Plan says 
authorization denied because IRF is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as a skilled nursing facility (SNF), on an intermittent basis at home with home health care, or 
in a long-term care setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that the enrollee would be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. The enrollee continues to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation doesnt support that she would meet 
criteria for admission to an acute inpatient rehabilitation facility. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Acthar Gel. 
 
You asked the Plan to pre-approve Acthar Gel. You say that you feel Acthar is medically necessary to help the 
enrolle regain control of her Multiple Sclerosis. The Plan denied your request. The Plan says the enrollee does 
not meet the requirements for approval. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Acthar Gel. Our reviewer says that 
Acthar Gel is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan 
requires a trial Glatopa, Gilenya, Ocrevus, Tecfidera, Aubagio, Tysabri, Avonex, Betaseron, or Refbif before 
they will approve the requested drug. Our reviewer found that in this case, the patient has not tried and failed 
the required drugs. Our physician reviewer also found that there is no documentation provided indicating that 
the Plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Acthar Gel have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Acthar Gel.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that your records do not support medical 
necessity for these services. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you would improve in a reasonable period of time as you were not showing any dangerousness to 
self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute 
threats of safety. You were cooperative and compliant with medication. It does  not appear medically necessary 
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care as you do not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal 
behaviors. Our physician reviewer found that your condition does not meet criteria for coverage of inpatient 
psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital 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 need to start therapy as soon as possible to get 
your strength back. You say that the longer you wait for rehabilitation, the longer you will have to stay in the 
hospital. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan 
says that the enrollee can safely receive the services needed in other settings. 
 
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 enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for left lower leg ischemia and had an above the knee amputation. The enrollee's medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the enrollee 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation 
correction and anatomical localization imaging; whole body (CPT code 78816) and PET radiopharmaceutical, 
diagnostic, for tumor identification, not otherwise classified (CPT code A9597). 
 
You asked the Plan to pre-approve the services. You say that the standard timeframe would endanger the 
enrollee's health because the enrollee cannot wait standard time frame for the scan and needs to have it now or 
it will impact their cancer staging and treatment. The Plan denied your request. The Plan says your request is 
not medically necessary because Medicare does not cover PET scans for initial anti-tumor treatment strategy 
for prostate cancer. 
 
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 services. Our physician reviewer 
found the record indicates that the enrollee has prostate cancer. The requested test is being utilized as part of 
initial staging prior to treatment. By rule, coverage for this indication is not available. The elements of the 
coverage criteria are not satisfied. The requested service cannot be 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization 
imaging; whole body (CPT code 78816) and PET radiopharmaceutical, diagnostic, for tumor identification, not 
otherwise classified (CPT code A9597).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve the inpatient hospital admission. You say that the documentation provided 
supports the need for an inpatient admission. The Plan denied your request. The Plan says the guidelines for 
coverage have not been met. The Plan says that the care the enrollee needs can be provided without an inpatient 
stay after the surgical procedure. 
 
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 pre-approve the inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for an inpatient admission are met in this 
case. Our physician reviewer found the enrollee has unilateral primary osteoarthritis of the right knee. Plans for 
elective arthroplasty of the right knee have been made and approved. The enrollee's recent notes did not 
describe the enrollee as being at high cardiovascular risk or being unstable to expect this lower risk procedure 
would likely require the enrollee to have inpatient services that would likely cross 2 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 hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says there is no 
documentation of failure of six weeks of therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our physician reviewer found 
that you experienced severe back pain for three weeks, with no known injury. There is no documentation of 
any abnormal neurological findings, failure of six weeks of therapy, or any documented medical emergency 
that supports the requested imaging. Therefore, the requested MR is 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 an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
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 do not need or want skilled nursing. You say 
you would prefer to get 3-4 hours of physical therapy a day, in order to decrease the time of stay. You say you 
want to facilitate your return home to live independently. The Plan denied your request. The Plan says 
authorization denied because IRF is not medically necessary and the enrollee's needs can be met at a lower 
level of care, such as skilled nursing facility (SNF). 
 
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 continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement. However, the documentation doesnt support that the 
enrollee would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication 
that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status.  
The enrollee can receive further 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 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 he enrollee currently meets full IRF criteria and the 
IRF is medically necessary to regain maximum function. The Plan denied your request. The Plan says 
authorization denied because IRF is not medically necessary and the enrollee's needs can be met at a lower 
level of care, such as a SNF, on an intermittent basis at home with home health care, or in a long-term care 
setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain his functional status. The member can receive further 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 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.