Persius/hicric huggingface dataset:
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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the records do not show that their rehab needs are complex and that they 
need to be seen 3 times per week for evaluation of functional and medical goals and progress. They do not need 
an intensive team for their care. The services they need can be provided safely in other settings, for example, 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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: 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 this is the setting that is most appropriate for the 
enrollee to reach the desired outcomes. The Plan denied your request. The Plan says the enrollee does not meet 
the guidelines 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 clinical documentation shows that the enrollee has active medical comorbidities 
and complex functional impairments. The evaluating therapy notes document that the enrollee has difficulty 
participating in therapy evaluations due to pain. Documentation shows that the enrollee would not be expected 
to tolerate an intensive rehabilitation regimen. IRF criteria not met.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the lower spine.  
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says you don't meet all the required criteria.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found there is lack of physical therapy or a home 
exercise program. Therefore, the request cannot be approved 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) of the lower spine.
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 care is medically necessary. 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 pancreatitis and urinary outlet obstruction. The 
enrollees 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. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Nulojix. 
 
You asked the Plan to pre-approve Nulojix. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the record does not show that the enrollee meets the indications for Nulojix. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Nulojix. Our reviewer says that the 
enrollee does not meet criteria for this drug. Our physician reviewer found Nulojix is not Food & Drug 
Administration (FDA) approved for cardiac transplant rejection prophylaxis. Its sole indication is renal 
transplant rejection prophylaxis. The requested use is not supported by one of the major drug compendia or by 
clinical research appearing in a Medicare-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nulojix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Nulojix.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM) 
system.  
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
and does not have a history of problematic hypoglycemia. Based on this information, we decided that Medicare 
rules for coverage of a FreeStyle Libre 2 CGM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM) system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy and Opdivo. 
 
You asked the Plan to pre-approve Yervoy and Opdivo. You say that the enrollee would be a great candidate 
for treatment with Yervoy and Opdivo. The Plan denied your request. The Plan says Yervoy and Opdivo 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 Yervoy and Opdivo. Our reviewer says 
that Yervoy and Opdivo is not medically necessary. Our physician reviewer found that the requested drugs 
Yervoy and Opdivo are not FDA approved or supported by one of the major drug compendia.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yervoy and Opdivo have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yervoy and Opdivo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a stabilization device. 
 
You asked the Plan to pre-approve the insertion of a stabilization device. You say that the enrollee's quality of 
life is severely reduced because of functional impairments caused by stenosis. You say that the enrollee 
attempted conservative treatment without long-term relief and this procedure is medically necessary. The Plan 
denied your request. The Plan says this device is still being studied to see if this treatment is reasonable and 
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 insertion of a stabilization device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that stabilization devices are experimental for stenosis.  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 insertion of a stabilization device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of a stabilization device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76380 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the CT is a post procedure follow up.  The Plan 
denied your request. The Plan says the procedure is inclusive to the main procedure.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 76380 is computed tomography (CT), limited or localized 
follow-up study. 
 
 We find that CPT code 76380 is not supported. The records show that a bronchoscopy procedure was provided 
that included imaging guidance. The records do not show that a separate procedure was provided. The records 
show that the CT imaging was part of the primary procedure. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 76380 billed for date of service October 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction, the frames, the single vision lens, the 
polycarbonate lens, the tint, and the prism provided from October 20, 2022, to November 18, 2022. 
 
You asked the Plan to pay for the vision services. You say that you could not wait for your regular appointment 
due to increased double vision. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, 
we decided that the Plan does not have to pay for the refraction, the frames, the single vision lens, the 
polycarbonate lens, the tint, and the prism provided from October 20, 2022, to November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass frames provided on January 7, 2023. 
 You asked the Plan to pay for the eyeglass frames. You say that you went out-of-network because the in-
network provider wanted to charge you $75 for using your own frames. The Plan denied your request. The Plan 
says the item is not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglass frames have not been met. Therefore, 
we decided that the Plan does not have to pay for the eyeglass frames provided on January 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve StimQ peripheral nervous system (PNS) system 
(64555). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of StimQ PNS system, the setting of 
chronic knee pain have not been demonstrated in the peer-reviewed literature. The Plan states there are limited 
published studies that show this to be an effective and/or safe treatment for the noted pathology. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident for the knee pain. Moreover, there is limited published, 
large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment 
for the noted pathology. No compelling rationale is presented, or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested StimQ PNS system, in this case, 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve StimQ peripheral nervous system (PNS) system (64555).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee's needs can be met at an alternate level of care.  
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning pillow (E0190). 
 
You asked the Plan to pre-approve a positioning pillow . You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  Therefore, we 
decided that the Plan does not have to pre-approve a positioning pillow (E0190).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
May 21, 2023, and forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care from May 21, 2023, and 
forward. You say that the continuation of inpatient mental health care from May 21, 2023, and forward is 
medically necessary. The Plan denied your request. The Plan says the continuation of inpatient mental health 
care from May 21, 2023, and forward is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continuation of inpatient mental 
health care from May 21, 2023, and forward. Our reviewer says that the continuation of inpatient mental health 
care from May 21, 2023, and forward is not medically necessary. Our physician reviewer found this enrollee 
did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger 
to herself or others and does not have auditory or visual hallucinations. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services were reasonably expected to 
improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. I am unable to 
find an individualized treatment plan however the entire record is not present. It did appear that the records 
were supervised and evaluated by a physician. Based upon review of the records provided, the enrollee does 
not meet the criteria for continued inpatient mental health care from May 21, 2023, and forward as this enrollee 
was not shown to be a danger to herself or others. No delusions, auditory or visual hallucinations noted. She 
was cooperative/compliant with treatment while not showing any threats to safety. 
 
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 continuation of inpatient mental health care from May 21, 2023, and 
forward have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation 
of inpatient mental health care from May 21, 2023, and forward.
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 not receiving much therapy services and 
need the services to get back to yourself and return home independently. The Plan denied your request. The 
Plan says the services you need can be provided safely in another setting 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 you do not require the intensity of services provided at an IRF. You are not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can 
be met 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.