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

 
We decided that the Plan does not have to pre-approve a kidney transplant to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that it is a life-or-death situation, and 
you need this authorization to be approved so you can have a better chance of life. You state you prefer to go to 
this hospital because it is closer to you, and you have never been to Gainesville. The Plan denied your request. 
The Plan says they have participating transplant hospitals that can provide services to you. 
 
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. 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 
a kidney transplant to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve repeat radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met. 
 
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 medically necessary. Our physician reviewer found the enrollee has lumbar spondylosis 
without myelopathy or radiculopathy. The pain level is documented as seven out of 10 on August 19, 2022. A 
right lumbar medial branch block provided 70 percent initial relief and lumbar RFA provided 75 to 80 percent 
relief for six months. The clinical documentation supports that the enrollee had a minimum of 50 percent 
improvement for at least six months, thus meeting the coverage criteria for repeat RFA. Repeat RFA is 
therefore reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve repeat radiofrequency ablation (RFA).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that that the enrollee currently meets LTAC 
admission under Medicare guidelines. The Plan denied your request. The Plan says the enrollee's records do not 
show it is medically necessary for an LTACH admission. 
 
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 has hypertension, chronic lung disease (COPD) and history of lung 
cancer requiring removal of part of her left lung, and back pain who was hospitalized on August 12, 2022 for 
confusion, trouble breathing, cough, and low oxygen levels. The enrollee had signs of lung infection on an x-
ray and had kidney damage. The enrollee has been treated for both of these and also for a flare of COPD. The 
records from August 30, 2022 show the enrollee was requiring a special type of oxygen delivery with inhaled 
medications for the COPD.  
 The records from August 30, 2022 show that the enrollee was requiring a specialty type of oxygen delivery 
device along with inhaled medications for COPD in order to maintain safe levels of oxygen in the blood. The 
enrollee also had a wound the left ankle that was surgically cleaned on August 30, 2022 and will require 
intravenous antibiotics until September 27, 2022. 
 
There is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is 
receiving the appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they are receiving 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter placement of intravascular stent(s), 
cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological 
supervision and interpretation; with distal embolic protection (CPT code 37215). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is at high risk of a stroke. The Plan 
denied your request. The Plan says the enrollee's request is not medically necessary because their records show 
they do not have any symptoms associated with left internal carotid artery stenosis and the stenosis is less than 
80% nor the enrollee is high-risk for left carotid endarterectomy. 
 
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 service. Our physician reviewer 
found the record indicates that the enrollee has a 50-59% carotid artery stenosis demonstrated by angiography 
and between a 60-79% stenosis as determined by duplex measured velocity. The record does not indicate the 
presence of symptoms related to the carotid artery disease.  The record does not indicate that the enrollee is at 
high risk for open endarterectomy or that the enrollee will be involved in an approved trial. 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter placement of intravascular stent(s), cervical carotid artery, open or 
percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with 
distal embolic protection (CPT code 37215).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
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 cardiac catheterization is covered when specific 
criteria are met. 
 
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 history of recurrent 
chest pain, both before and since a radionuclide stress test, without change in character of symptoms. An 
echocardiogram was also normal. The guidelines do not support the need for cardiac catherization in this 
setting. At this time, cardiac catheterization is not considered medically appropriate and necessary in the 
enrollee's 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cardiac catheterization.
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. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for SNF care and can be treated in 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require skilled nursing and/or skilled therapy services on a daily 
basis. Although further rehabilitation services would be appropriate to improve function, as a practical matter, 
the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The 
enrollee 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says medical studies have not proven that this procedure is helpful for 
the treatment of your 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 a skilled nursing facility bed cannot be 
found for the enrollee due to the enrollees morbid obesity. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for admission to a LTACH. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of LTACH 
admission. The Plan denied your request. The Plan says admission was denied as the enrollee does not require 
complex respiratory services or ventilator weaning. The enrollee is not medically stable for transfer 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 the enrollee was admitted to the acute care hospital with respiratory failure, COVID-
19 infection, and dehydration in the setting of pulmonary fibrosis, treated with fluids, steroids, antibiotics, 
oxygen support, and was treated with chronic wound care. Recent notes describe the enrollee as improving 
with treatment and approaching baseline oxygen requirements with stable vitals. The enrollee appears to be 
improving and requires additional short-term additional acute care services that can safely be administered at 
the current facility until more stable and appropriate for a lower level of care. The enrollee does not require 
services at the LTACH that are not available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says the member is receiving appropriate inpatient acute 
care and does not require transfer to a LTACH. 
 
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 in this case the enrollee was admitted with bacteremia in the setting of psoriatic 
arthritis flare with 95% skin sloughing. The record indicates that the enrollee is improving but still require 
acute care services before transitioning to a lower level of care. 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 he is not currently receiving but that would be available at the LTACH facility. The elements of 
the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the requested service. The Plan denied your 
request. The Plan says based on Medicare guidelines and the information we have about your condition you do 
not meet the requirements for approval. 
 
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 were admitted for sepsis, pneumonia, and respiratory failure. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While you have a need for physical 
or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has unfavorable 
intermediate risk T1c,N0, M0 prostate cancer, with a prostate specific antigen level of 13.84 and Gleason score 
3+4=7. The enrollee has a history of urinary tract infection. The National Comprehensive Cancel Network 
(NCCN) Panel believes that no clear evidence supports a benefit or decrement to proton therapy over intensity 
modulated radiation therapy (IMRT) for either treatment efficacy or long-term toxicity. Conventionally 
fractionated prostate proton therapy can be considered a reasonable alternative to x-ray-based regimens at 
clinics with appropriate technology, physics, and clinical expertise. 
 
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 proton beam therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for admission to 
an IRF that is needed. The Plan denied your request. The Plan says based on Medicare guidelines the IRF 
services you are requesting do not meet the requirements for approval. 
 
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 was admitted for abdominal pain and surgical management of 
pancreatic cancer. Medical problems are stable. There are no complex nursing or rehabilitation needs. While 
the enrollee has a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuedexta capsule. 
 
You asked the Plan to pre-approve Nuedexta capsule. You say that this 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 Nuedexta capsule.  
 
Benefits for Nuedexta capsule 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the weight loss surgery (CPT code 43659). 
 
You asked the Plan to pre-approve the surgery. You say that the surgery is medically necessary. The Plan 
denied your request. The Plan says repeat bariatric surgery is generally not reasonable and necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the surgery have not been met. Review of the file shows that the 
enrollee had weight loss surgery in 2012. Medicare does not cover repeat weight loss surgery for any reason. 
Therefore, we decided that the Plan does not have to pre-approve the weight loss surgery (CPT code 43659).