Persius/hicric huggingface dataset:
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 you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements for approval. 
 
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 subdural hematomas, 
subarachnoid hemorrhage following a fall, and complicated by pneumonia and pacemaker placement. Recent 
notes describe the enrollee as now on oxygen via nasal cannula but still on nasogastric tube and IV antibiotics 
but is improving with speech therapy, physical therapy and occupational therapy. The enrollee appears to be 
more stable but requires 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 the LTACH services.
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 you are requesting reconsideration of the 
denied authorization for LTACH. The Plan denied your request. The Plan says based on Medicare guidelines, 
the long-term acute care hospital services you are requesting do not meet the requirements for approval. 
 
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 peritonitis, pneumonia 
following recent laparotomy and bowel resection with ileostomy, requiring IV antibiotics and was complicated 
by acute respiratory failure requiring mechanical ventilation and trach placement. That was complicated by 
recent new abscesses found on a computed tomography scan requiring antibiotics and ileostomy revision with 
wound care including wound VAC and vasopressors. Recent notes describe the enrollee as now tolerating the 
trach collar, with improving encephalopathy and leukocytosis, and stable vitals without the need for 
vasopressors.  The enrollee appears to be more stable and only requires 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 the LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 home health physical therapy visits. 
 
You asked the Plan to pre-approve 5 home health physical therapy visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 5 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has 
determined that the records do not show that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance 
program to maintain your condition and/or prevent deterioration. The records do not show that skilled therapy 
services are required to effectively provide treatment, care, and/or services in order to improve your level of 
function, or to establish/perform a maintenance program to maintain your level of function and/or prevent 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 5 home health physical therapy visits.
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 you are appealing the denial of 
admission. The Plan denied your request. The Plan says admission to LTACH was denied as not meeting 
criteria, is not medically necessary, and continued acute hospital stay was offered, until you could discharge to 
a lower level of care such as skilled nursing facility. 
 
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 to the acute care hospital with endocarditis, bacteremia, poor oral 
intake, and agitation. You were treated with antibiotics, fluids, and diuresis complicated by bradycardia 
requiring a medication adjustment. Recent notes describe you now with more stable kidney function and vitals 
requiring ongoing intravenous antibiotics for another three weeks.  
 
 You appear to be more stable and improving and only require short-term additional acute care services that can 
safely be administered at the current facility until more appropriate for a lower level of care. You do 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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Cinacalcet tablet. 
 
You asked the Plan to pre-approve Cinacalcet. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Cinacalcet 
tablet.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crutch substitute (CPT code E0118). 
 
You asked the Plan to pre-approve the crutch substitute. You say that the item is necessary. The Plan denied 
your request. The Plan says there is insufficient published clinical literature demonstrating the safety and 
effectiveness in the Medicare population to establish the medical necessity for these products. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. We looked at the file and Medicare rules. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of the crutch substitute have 
been met. Medical documentation was not provided to verify if the item is necessary. Therefore, we decided 
that the Plan does not have to pre-approve the crutch substitute (CPT code E0118).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would extremely benefit from inpatient 
physical therapy to be monitored and could gain the strength and ability needed in order to continue to live 
before being diagnosed with COVID-19. The Plan denied your request. The Plan says admission to IRF was 
denied as not meeting criteria, is not medically necessary, and a lower level of care might be appropriate. Care 
can be provided safely at an alternate level of care, for example, at home with supervision and home health. 
 
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 is deconditioned and does not have intensive or complex 
rehabilitation needs. The enrollee has reduced capacity to respond to intensive rehabilitation. The enrollee does 
not require frequent physiatry oversight. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had a below the knee amputation and is 
not able to pivot from bed to chair. The enrollee needs rehabilitation to gain strength and gain mobility back. 
The Plan denied your request. The Plan says based on Medicare guidelines, the inpatient rehabilitation facility 
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 most recent therapy notes indicate that the enrollee requires assistance with 
bed mobility and toileting. The enrollee is able to transfer with minimal assistance. 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 25, 
2021. 
 
You asked the Plan to pay for the services. You say that the claim for this date of service is payable and should 
be processed. The Plan denied your request. The Plan says fee for service Medicare continues to cover the 
beneficiary through the end of the month when hospice is revoked. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on March 12, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided to the enrollee on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are not well enough to go home as 
you don't have anyone to take care of you. The Plan denied your request. The Plan says based on Medicare 
guidelines, the long term acute care hospital services you are requesting do not meet the requirements for 
approval. 
 
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 have chronic obstructive pulmonary disease (COPD) on home oxygen, were 
admitted to the acute care hospital with acute respiratory failure, COPD exacerbation, congestive heart failure, 
and chronic kidney disease in the setting of having been recently treated for COVID-19 pneumonia.  
 
 
 You were treated with oxygen support, intravenous steroids, breathing treatments, BiPAP and wound care for 
skin ulcers. Recent notes describe you as now tolerating high flow oxygen support via nasal cannula with 
BiPAP at night only with antibiotics having been completed. You appear to be more stable and improving and 
only require short-term additional acute care services that can safely be administered at the current facility until 
closer to baseline and more appropriate for a lower level of care. You do 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 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 there is not a reasonable expectation that this individual will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would clearly benefit from 
comprehensive therapy, who has an acute medical diagnosis that requires close physician oversite in the 
inpatient setting with twenty-four hour nursing care. The Plan denied your request. The Plan says IRF 
admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee progressed from mod assist to comprehensive geriatric assessment 
with acute inpatient therapy averaging fifteen to thirty minutes per day. By their own performance the enrollee 
does not require intensive rehabilitation or frequent physiatry oversight. The enrollee has access to 
rehabilitation that meets these needs without admission to an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve spinal cord stimulator electrodes. 
 
You asked the Plan to pre-approve spinal cord stimulator electrodes. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless 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 spinal cord stimulator electrodes. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the electrodes are 
charged separately. Two electrode leads with eight nodes each are medically reasonable and 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 spinal cord stimulator electrodes have been met. Therefore, we decided that the 
Plan has to pre-approve spinal cord stimulator electrodes.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
for the enrollee. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee cannot tolerate the trauma 
of multiple and successive lacerations to the same finger and that this is the only option at this point to properly 
monitor blood sugar levels. The Plan denied your request. The Plan says that the enrollee is not using insulin 
three or more times per day or is using an insulin pump. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
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 you are requesting SNF services for the enrollee. 
The Plan denied your request. The Plan says rules for SNF care have not been met. 
 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 daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.