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 enrollees current ongoing conditions 
and needs are a priority, and potential recovery can be met at a faster rate in an LTACH setting. The Plan 
denied your request. The Plan says the enrollee does not meet the guidelines for care in an 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 the enrollee remains acutely ill with several ongoing medical issues including the 
need for a ventilator, cardiac arrhythmias and severe debilitation. It is not clear that the enrollee remains stable 
for transfer. Based on Medicare policy, enrollees appropriate for LTACH are those whose complex clinical 
conditions predictably place them in a population that require continued prolonged acute hospitalization. Such 
enrollees are generally characterized as having typically long-term issues such as complex wound care, 
prolonged ventilator weaning, or complex rehabilitation needs in the setting of ongoing acute care needs. The 
ventilation weaning is not the only issue in this case. 
 
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 the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. The Plan denied your request. The Plan says the 
genicular nerve block is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is the subject of ongoing clinical trials and is considered an experimental and investigational 
therapy. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
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 admission is a medical necessity. The 
Plan denied your request. The Plan says according to the information reviewed on appeal, the requested service 
is not medically necessary.  
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services and these have not been 
denied.  The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your family is concerned that by not having a doctor 
on staff will get you back into the emergency room. The Plan denied your request. The Plan says ongoing 
skilled care can be provided in an alternative 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the 
medical records support 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 you 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T10 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T10 kyphoplasty. You say that  the kyphoplasty is medically necessary. The 
Plan denied your request. The Plan says the kyphoplasty is not medically necessary. The Plan says the enrollee 
has chronic compression fractures and no imaging documenting a compression fracture at T10. 
 
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 T10 kyphoplasty. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no imaging study showing an acute fracture less than 12 weeks.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T10 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T10 kyphoplasty (22513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous of minimally invasive arthrodesis at the 
sacroiliac (SI) joint 
 
You asked the Plan to pre-approve the SI joint arthrodesis. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the arthrodesis is not medically necessary. The Plan says the enrollee 
does not show six months of intensive, non-operative treatment, spinal imaging shows neuroforaminal stenosis 
and other degenerative conditions, and the enrollee only had one diagnostic injection. 
 
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 SI joint arthrodesis. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no SI joint instability or lesion, and there are other lumbar degenerative changes. SI 
joint fusion for degenerative back pain is considered experimental. 
 
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 SI joint arthrodesis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous of minimally invasive arthrodesis at the sacroiliac (SI) joint
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  the clinical documentation provided 
supports the medical necessity for LTACH admission. The Plan denied your request. The Plan says the 
requested LTACH services are not medically necessary, reasonable, or appropriate for the diagnosis and 
condition of the member at this time. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services.  
 
 
 Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee appears to have  a very poor prognosis and only requires short-
term additional acute care services that can safely be provided at the current facility until more 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. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. 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 the 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 an intensive team and needs close 
medical treatment. The Plan denied your request. The Plan says the IRF care is not medically necessary, and 
the enrollee's needs can be met at a lower level of care such as a skilled nursing facility, home with home 
health services, or home with outpatient therapy 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for an infection of an artificial hip joint. The enrollee's 
medical problems are stable, and there are no complex nursing or rehabilitation needs. 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. 
 
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  the enrollee needs rehabilitation in order to gain 
strength. The Plan denied your request. The Plan says the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for a fall. The enrollee's medical problems are stable, and 
there are no complex nursing or rehabilitation needs. 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. 
 
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 pre-approve office visits (99205, 99215) with a cardiothoracic 
surgeon to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you must receive services from a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99205, 99215) with a cardiothoracic surgeon to be provided by an out-of-network (OON) 
provider.
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 are requesting an expedited appeal for the denial 
of acute inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare guidelines for services in 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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 the interspinous-interlaminar fusion device lumbar - 
Minuteman device. 
 
You asked the Plan to pre-approve the Minuteman device. You say that the Minuteman device is not medically 
necessary. The Plan says that the use of this device as a stand-alone procedure has not been shown to be safe 
and effective in long-term studies. The Plan denied your request. The Plan says the enrollee has severe pain, 
and the surgery is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Minuteman device. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the minuteman device is experimental, and 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 the Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the interspinous-interlaminar fusion device lumbar - Minuteman device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2311) and a 
footplate cover with extension (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and the footplate cover. You say that you are 
appealing the denial. The Plan denied your request. The Plan says the upgraded electronics are not medically 
necessary. The Plan also says that code K0108 is unbundled and miscoded. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say miscellaneous options, accessories, or replacement parts for 
wheelchairs that do not have a specific HCPCS code and are not included in another code should be coded 
K0108 
 
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 upgraded electronics and the 
footplate cover. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee has sufficient strength and function 
in the upper extremities to manage the standard power drive controls. The footplate cover is miscoded as there 
is already a HCPCS code for the footplate. 
 
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 upgraded electronics and the footplate cover have not been met. Therefore, 
we decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2311) and a 
footplate cover with extension (K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee needs the medication as soon as possible.  
The Plan denied your request. The Plan says Darzalex Faspro is not medically necessary.  
 
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 the drug. Our reviewer says that 
Darzalex Faspro is not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of 
multiple myeloma. The FDA has not stated that the requested drug is indicated for the enrollee's condition. The 
requested drug is also not supported by one of the major drug compendia or by clinical research. Therefore, the 
elements of coverage criteria are not satisfied, and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Darzalex Faspro.