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 IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says IRF care 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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
does not support that he 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 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 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT) 
 
You asked the Plan to pre-approve the IMRT. You say that the requested services are medically necessary. The 
Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee meets the criteria for medically necessary services. The enrollee has been treated 
with Carboplatin/Etoposide/Atezo along with radiation therapy. Planning for consolidative radiotherapy with 
intensity-modulated radiation therapy (IMRT) is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the IMRT have been met. Therefore, we decided that the Plan has to pre-
approve intensity-modulated radiation therapy (IMRT)  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 5, 
2023, to August 3, 2023. 
 You asked the Plan to pay for SNF care. You say that the records provided support the need for the SNF care in 
dispute. The Plan denied your request. The Plan says there were no daily skilled nursing or daily skilled 
therapy needs. 
 
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 pay for 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 had dementia, muscle weakness and hypothyroidism. The enrollee 
received oral medications, had stable vital signs, and was up with wandering behavior. The enrollee received 
physical therapy and occupational therapy. The enrollee was at an independent level with functional mobility 
and activities of daily living. On the dates of service in dispute, there were no identifiable skilled nursing 
service needs or identifiable skilled therapy service needs. The enrollee did not require skilled nursing or 
therapy services on a daily basis. The enrollee did not meet the severity of illness or intensity of service criteria 
for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from July 5, 2023, to August 3, 2023.
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 this is medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 that the documentation is reviewed in its entirety. At the time of admission, the 
enrollee required skilled rehab services to improve function due to weakness and deconditioning. There were 
no skilled nursing needs. As of the last covered day, the enrollee did not require any skilled nursing or rehab 
services on a daily basis. The enrollee was not expected to make measurable gains within a reasonable and 
predictable period of time or require skilled therapy to prevent deterioration with mobility or self-care 
tasks.  The member did not require skilled therapy to establish a safe and effective maintenance program.  As a 
practical matter, the member did not require any skilled services on an inpatient basis, at a skilled level of care 
as of 07/09/2023. The enrollee did not have any parental medications, complex wound care or nutrition given 
via a feeding tube. The enrollees function was at or near her prior level of function and she could be 
discharged to a lower level of care for further services. As of 07/09/2023, the enrollee required custodial 
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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot and ankle (L5968, L5981) for a lower-
limb prosthesis. 
 
You asked the Plan to pre-approve the items. You say that the requested items are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested items are not 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 the items. Our physician reviewer 
found the physician documentation does not support that the enrollee requires a K3 level foot. The prosthetist is 
the vendor and recommends the Proteor Kinterra K3 foot and ankle, but this is not supported in the physician 
documents. The requested foot and ankle exceed the enrollee's needs. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an advanced foot and ankle (L5968, L5981) for a lower-limb prosthesis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4-5 fusion with the Aurora Spine ZIP interspinous 
fixation with allograft (22612, 22840, 20930). 
 
You asked the Plan to pre-approve L4-5 fusion with the Aurora Spine ZIP interspinous fixation with allograft. 
You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not 
been established. Therefore, coverage criteria 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 L4-5 fusion with the Aurora Spine ZIP 
interspinous fixation with allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the aurora zip device is 
experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L4-5 fusion with the Aurora Spine ZIP interspinous fixation with allograft have 
not been met. Therefore, we decided that the Plan does not have to pre-approve L4-5 fusion with the Aurora 
Spine ZIP interspinous fixation with allograft (22612, 22840, 20930).
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 IRF services will help in the enrollee's recovery. 
The Plan denied your request. The Plan says the IRF services are 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
does not support that he 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 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) admission and 
services after January 19, 2024. 
 You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says continuation of SNF is not medically 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that at the time of admission, the enrollee required skilled rehab services to improve 
function due to weakness and deconditioning.  There were no skilled nursing needs. As of the last covered day, 
the enrollee did not require any skilled nursing or rehab services on a daily basis. The enrollee was not 
expected to make measurable gains within a reasonable and predictable period of time or require skilled 
therapy to prevent deterioration with mobility or self-care tasks. The enrollee did not require skilled therapy to 
establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any 
skilled services on an inpatient basis, at a skilled level of care as of 01/19/2024. The enrollee did not have any 
parental medications, complex wound care or nutrition given via a feeding tube. The enrollees function was at 
or near her prior level of function and she could be discharged to a lower level of care for further services.  As 
of 01/19/2024, the enrollee required custodial 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) admission and services after January 19, 2024.
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 were unable to get admitted to the hospital but 
require SNF care. The Plan denied your request. The Plan says the request is not medically 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require skilled nursing services, with the specialized skill, knowledge 
and judgment of a skilled professional nurse. to safely and effectively provide medically necessary and 
reasonable treatment in a SNF. There is no evidence of new enteral feeding, complex wound care or other SNF 
level skilled nursing need. You do not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist  to safely and effectively provide medically necessary and reasonable 
treatment only in a SNF. You do not require daily skilled nursing or daily skilled therapy services or a 
combination of these services. As a practical matter, while you may benefit from additional therapy, you do not 
require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 11, 
2023, to July 27, 2023. 
 
You asked the Plan to pay for SNF care. You say that the records provided support the need for SNF care. The 
Plan denied your request. The Plan says the enrollee did not require daily skilled services and their needs could 
have been met at 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 pay for 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 received oral medications and had stable vital signs. The enrollee 
received physical therapy and occupational therapy. The enrollee was at a stand-by assist level with functional 
mobility, including gait to 100 feet. The enrollee required varying assist with activities of daily living. There 
were no identifiable skilled nursing or skilled therapy service needs. The enrollee did not meet the severity of 
illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from July 11, 2023, to July 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and ready 
for the next level of care, which is LTACH. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient care and does not require a transfer to the 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 that the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until 
appropriate for transfer to 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 the LTACH is not medically necessary as it would not be 
clinically advantageous. 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories (E0955, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2603, K0842, E1028). 
 
You asked the Plan to pre-approve a group 2 power wheelchair and accessories. 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 power mobility dvices are covered when specific 
criteria are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be 
denied. 
 
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 a group 2 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
record indicates the enrollee does not require a group 2 power wheelchair to complete self care activities in the 
home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 2 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories (E0955, E1007, 
E1012, E1028, E2311, E2313, E2361, E2377, E2603, K0842, E1028).
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 not medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is 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 that admission to an IRF is not medically necessary. The enrollee has a fractured 
humerus, and is non weight bearing in that arm. The enrollee is functioning at a home care 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.