Persius/hicric huggingface dataset:
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 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 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 more stable and 
appropriate for transfer to a lower level of care soon. The enrollee does not require services at the LTACH that 
are not already 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT PNS. 
 
You asked the Plan to pre-approve the PNS. You say that this procedure is necessary to address pain and 
restore function. The Plan denied your request. The Plan says experimental and investigational procedures are 
not covered. 
 
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 PNS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the PNS is considered experimental/investigational and is not medically necessary for the 
treatment of chronic low back pain. 
 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 PNS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a SPRINT PNS.
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 the enrollee needs skilled services due to a history 
of falling and injuries. The Plan denied your request. The Plan says the enrollee is currently enrolled in hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. 
 
 The record shows the enrollee is currently enrolled under the Medicare hospice benefit. The Plan's coverage 
does not resume until December 1, 2023. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) care.
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 very motivated for to return to prior 
level of function and go home safely. The Plan denied your request. The Plan says the enrollee's condition does 
not meet all of the requirements for inpatient rehabilitation admission. The Plan says services may be provided 
at a lower level of care.  
 
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.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the services (71045) provided on April 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 24, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the services (71045) provided on April 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the request is medically necessary. The Plan denied 
your request. The Plan says the requested use of this drug is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
requested use of Keytruda is not supported. Our physician reviewer found the Food and Drug Administration 
has not stated that the requested drug is indicated for your specific condition. The Medicare-approved cancer 
drug compendia do not contain a supportive citation for the use of the requested drug in your clinical situation. No literature from Medicare-approved cancer journals were submitted for review. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
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 uses a walker and is unable to walk , eat 
or get dressed on their own because they have cognitive deficit which wont allow them to adapt on their own. 
The Plan denied your request. The Plan says an 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 that the enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that you do not agree with this denial. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
records shows that appropriate home health skilled physical therapy goals have been met with the services that 
have already been provided. The reviewer also found that the records do not show that 10 additional home 
health skilled physical therapy visits are required to effectively provide treatment, care, and/or services in order 
to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the 
patient's 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional home health physical therapy visits.
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 medical records provided support the need for 
the requested IRF admission The Plan denied your request. The Plan says the enrollee does not meet the 
medical necessity criteria for IRF admission.  
 
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 
doesnt support that they 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 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 you say that you disagree with the denial for the 
admission to an IRF. The Plan denied your request. The Plan says these 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The member does not require treatment by multiple therapies. 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 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 they would meet criteria for admission to an acute inpatient rehabilitation facility.  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autologous transfer of liposuctioned fat into the thumb 
carpometacarpal joint (15773, 64772). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you were told that code 15773 is not 
being covered. The Plan denied your request. The Plan says this is considered experimental and therefore is not 
covered. 
 
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 surgical procedure. Our reviewer 
says that the requested surgical procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found limited published, large-scale, long-term peer-reviewed literature shows this 
request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to corroborate the requested procedure is as safe/effective as the standard treatment. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the requested autologous transfer of liposuctioned fat into the thumb 
carpometacarpal joint 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 the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve autologous transfer of liposuctioned fat into the thumb carpometacarpal joint 
(15773, 64772).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 Home Health (HH) Skilled Nursing (SN) visits. 
 
You asked the Plan to pre-approve home health services. You say that the requested 5 HH SN visits are 
medically necessary. The Plan denied your request. The Plan says the requested 5 HH SN visits are not 
medically necessary. 
 
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 home health services. Our reviewer 
says that the requested 5 HH SN visits are not medically necessary. Our physician reviewer found based on the 
documentation provided, the enrollee does not have documented skilled nursing needs (i.e., IVs, complex 
wound care, new ostomy).  As such, the requested HH SN services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 5 Home Health (HH) Skilled Nursing (SN) visits.
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 a high risk for falls, Injury, and re-
admission to acute care if they don't receive the requested inpatient rehabilitation facility (IRF) services. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (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 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 lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fungal Infection PCR (polymerase chain reaction) panel 
(87798 x13, 87481 x5, 87551 x2) provided August 18, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that these procedure codes are medically 
necessary and is not deemed experimental or investigational. The supporting documentation is attached for review. The Plan denied your request. The Plan says the service is considered to be experimental or 
investigational and excluded from coverage. 
 
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 pay for the laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found after careful review of the enclosed information and the pertinent guidelines for this case, the 
PCR testing for this enrollees toenail was not medically reasonable or necessary. It is well established in the 
medical documentation that this enrollee is suffering with thick painful toenails that demonstrate 
onychogryphosis. A right hallux toenail specimen was taken and sent for PCR testing to evaluate for 
pathogens. The longstanding standard of care for the evaluation of fungus in toenails is the performance of both 
potassium hydroxide (KOH) and fungal culture on a toenail specimen. These laboratory tests are inexpensive, 
sensitive, and specific. It is unclear as to why this enrollees toenail required PCR testing as compared to KOH 
and fungal culture. Therefore, the PCR testing of this enrollees right hallux toenail was not medically 
reasonable or necessary at this time. 
 
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 laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Fungal Infection PCR (polymerase chain reaction) panel (87798 x13, 87481 x5, 
87551 x2) provided August 18, 2023.