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 enrollee's current medical condition 
requires an LTACH admission. The Plan denied your request. The Plan says the required care can be received 
at an alternate setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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. The enrollee is 
receiving appropriate care at the present acute care hospital. 
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs post rehab to raise their blood 
pressure and regain their mobility. The Plan denied your request. The Plan says the enrollee does not meet all 
the required Medicare criteria for admission to an IRF. 
 
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 medical records do not support the need for admission to an IRF. The enrollee 
does require physical and occupational therapy services. The enrollee's rehab needs can be provided in an 
alternate and lower intensity setting such as 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 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had an amputation and need rehabilitation as 
well as getting fitted for your prosthesis. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and your needs can be met in another setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0863) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the enrollee does 
not have a qualifying diagnosis for the requested power wheelchair. 
 
 
 The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy, or congenital skeletal deformity. As the requested power wheelchair is not necessary for the 
enrollees condition, the accessories are not covered. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 power wheelchair (K0863) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823) and sealed 
batteries (E2363). 
 
You asked the Plan to pre-approve a power wheelchair and batteries. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the power wheelchair and accessories 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and batteries. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee is 
ambulating with a cane or walker but may be functionally non-ambulatory with these assistive devices due to 
pain, weakness, and lack of endurance. However, the mobility evaluation and clinical documentation provided 
is insufficient in terms of the enrollees graded upper extremity strength and range of motion and why she 
cannot use a manual wheelchair for mobility and her daily activities. Additionally, the enrollee is independent 
with transfers, and it is unclear why she cannot use a power scooter for mobility. 
 
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 power wheelchair and batteries have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Group 2 power wheelchair (K0823) and sealed batteries (E2363).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pluvicto (A9607). 
 
You asked the Plan to pre-approve Pluvicto. You say that the enrollee is not comfortable with the toxicity and 
side effects of chemotherapy. The Plan denied your request. The Plan says the enrollee refused to try the first 
line drug treatment.  
 
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 Pluvicto. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the drug compendia and FDA support 
that taxotere chemotherapy is required before trying Pluvicto. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pluvicto have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pluvicto (A9607).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance (eg, proton) imaging (MRI), 
pelvis; without contrast material(s), followed by contrast material(s) and further sequences (72197) and the 
MRI, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences 
(74183). 
 
You asked the Plan to pre-approve the MRIs. You say that the MRIs are medically necessary. The Plan denied 
your request. The Plan says the criteria for approval have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRIs. Our physician reviewer 
found the working diagnosis is irritable bowel syndrome. The enrollee recently has a normal 
esophagogastoduodenoscopy (EGD). The referring clinician states the enrollee has had multiple x-rays and 
computed tomography (CT) scans in the past (no reports enclosed) and for that reason has ordered MRI. Note: 
the enrollee is 85 years old so the concern for radiation dose would be minimal at best. The history and 
physical findings do not provide adequate indication for MRI of the abdomen and pelvis and as the Health Plan 
has indicated a CT of the abdomen and pelvis would be approved if ordered.  
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 MRIs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the magnetic resonance (eg, proton) imaging (MRI), pelvis; without contrast material(s), 
followed by contrast material(s) and further sequences (72197) and the MRI, abdomen; without contrast 
material(s), followed by with contrast material(s) and further sequences (74183).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three surgical extractions (D7210). 
 
You asked the Plan to pre-approve the surgical extractions. You say that you need your teeth pulled due to 
medical problems. You also say that you cannot eat and are in pain. The Plan denied your request. The Plan 
says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service has been exhausted because one surgical extraction has already 
been approved for coverage. Therefore, we decided that the Plan does not have to pre-approve three surgical 
extractions (D7210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0850) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the requested 
power wheelchair and accessories are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the medical 
records do not indicate that the enrollee requires a power mobility device to complete his ADLs. As the power 
wheelchair base is not medically necessary. the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0850) and accessories.
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's clinical condition does not meet the criteria for admission to 
an IRF.  
 
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 medically stable. While the enrollee may benefit from physical and 
occupational therapy their rehab needs can be met in an alternate setting such as 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a preventive procedure (D1999), alveoloplasty not in 
conjunction with extractions (D7320), removal of torus palatinus (D7472), first 15 minutes of deep 
sedation/general anesthesia (D9222), each subsequent 15-minute increment of deep sedation/general anesthesia 
(D9223), and therapeutic parenteral drug (D9610). 
 You asked the Plan to pre-approve a preventive procedure, alveoloplasty, removal of torus palatinus, deep 
sedation/general anesthesia services, and therapeutic parenteral drug. You say that you would like these 
services to be approved because they are medically necessary and so your dentures can fit in your mouth. The 
Plan denied your request. The Plan says the requested codes are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
preventive procedure (D1999), alveoloplasty not in conjunction with extractions (D7320), removal of torus 
palatinus (D7472), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15-minute 
increment of deep sedation/general anesthesia (D9223), and therapeutic parenteral drug (D9610).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the chart notes state the enrollee's decline in 
health and showing how BIPAP or oxygen is not effective. You say that the enrollee is in need of constant 
ventilation. You also say that without it the enrollee is at risk of continuing hospitalization and/or death. The 
Plan denied your request. The Plan says ventilators used to provide continuous positive airway pressure 
(CPAP) or bilevel positive airway pressure (BiPAP) therapy will be denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 ventilator. Our reviewer says that 
the ventilator is not medically necessary. Our physician reviewer found the provided documentation indicates 
the enrollee has been diagnosed with chronic obstructive pulmonary disease (COPD), obstructive sleep apnea 
untreated, coronary artery disease, and heart failure with reduced ejection fraction (HFrEF). The reviewer 
found that the enrollee's arterial blood gas (ABG) was consistent with acute on chronic hyper carbic respiratory 
failure which improved with BiPAP.  Multiple previous blood gases have shown carbon dioxide (CO2) 
retention. There are no pulmonary function tests in the record. There is no diagnosis of thoracic restrictive 
disease or neuromuscular disease. Therefore, the reviewer found that the requested ventilator 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an in-home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with power tilt and recline, 
and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that you 
want to appeal this denial. The Plan denied your request. The Plan says the enrollee can go to an out-of-
network provider but still pay the in-network cost sharing only if there is no in-network provider that can 
provide the requested service. The Plan says that the notes do not show that the enrollee needs both of these 
power options. The Plan also says that the upgraded electronics are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria have been 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that a Group 3 power wheelchair with power tilt and recline is not 
medically necessary. Our physician reviewer found the provided documentation does not support that the 
enrollee's condition requires the requested power options. The reviewer found that the enrollee has adequate 
upper body strength to manage a standard power drive control. Therefore, the reviewer found that a Group 3 
power wheelchair with power tilt and recline 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 a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with power tilt 
and recline, and accessories.
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 you are wanting to become independent again and an 
acute inpatient rehabilitation facility can help get you there. You say that you can participate in the required 3 
hours of therapy that you will not get in a nursing facility. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and your needs can be met in other settings.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 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 Home Health Aide services. 
 
You asked the Plan to pre-approve Home Health Aide services. You say that you do not agree with the denial 
of this appeal. The Plan denied your request. The Plan says the enrollee does not meet criteria for a Home 
Health Aide service. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Home Health Aide services have not been met. Specifically, we find that the services at issue in 
this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
Home Health Aide services.