Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient admission 
following an elective and approved left reverse total shoulder arthroplasty is medically necessary. The Plan 
denied your request. The Plan says an inpatient admission following an elective and approved left reverse total 
shoulder arthroplasty is not medically necessary as this surgery is currently approved as an ambulatory 
procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the enrollee is to undergo a procedure that is not on the inpatient only 
list and is not expected to require two midnights of inpatient level care. There is no documentation of 
uncontrolled co-morbidities, which clearly necessitate a prolonged (i.e., two midnight) stay. The enrollee 
should present for, undergo and be monitored following the procedure as an outpatient. Should complications 
arise, necessitating a prolonged stay, the enrollee can be converted to inpatient status at that time under the 
two-midnight rule. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that you are requesting reconsideration to evaluate for 
any sites of metastatic disease. You say the enrollee was originally diagnosed with prostate cancer in May, 
2022 and underwent initial treatment with androgen deprivation therapy and radiation treatment. You say 
following completion of treatment, the enrollees prostate-specific antigen (PSA) has steadily increased. The 
Plan denied your request. The Plan says that it is not medically necessary to use this test to plan initial 
treatment for this type of cancer. The Plan says a PET scan may be used when treatment is completed and there 
is a suspicion that the cancer has come back. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found a prostate-specific membrane antigen (PSMA) 
PET scan is approved and recommended by the Food and Drug Administration (FDA) for patients who have 
suspected metastasis and candidates for initial definitive therapy, as well as those who are suspected to have a 
recurrence of prostate cancer with a rising PSA after definitive 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 a PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an 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 still be somewhat unstable and requires additional acute care 
services that can safely be provided at the acute care facility until more stable and appropriate for transfer. The 
enrollee does not require services at the LTACH that are not already available at the current facility. There are 
no services at the LTACH that the enrollee requires, that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 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 you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met  
 
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's medical complexity does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The enrollee does not require an intensive 
rehabilitation therapy and it is unclear if they would tolerate it. There is no reasonable expectation that the 
enrollee will be able to benefit from the intensive rehabilitation 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: 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 SNF care is medically necessary since you cannot 
walk on your own. The Plan denied your request. The Plan says the services the enrollee requires can safely be 
received at a different setting, for example, home with home health, in residential care, or home with close 
follow-up with your doctor. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the limited documentation provided, you do not qualify for SNF coverage. 
You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You 
are non-ambulatory and dependent for activities for daily living at baseline. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of your condition. Your care needs can, 
as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
  You asked the Plan to pre-approve SNF care. You say that the enrollee is being denied skilled occupational 
therapy services related to range of motion and they are showing signs of decreased range of motion in their 
fingers and wrist while holding their fingers in a flexed position. The Plan denied your request. The Plan says a 
SNF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing home health visits (G0299). 
 You asked the Plan to pre-approve home health services. You say that you need these services to continue to 
rebuild your strength. The Plan denied your request. The Plan says this request is not medically necessary 
because your records do not show that you are under the care of a physician or other allowed practitioner who 
has developed and certified a plan of care. 
 
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 you are noted 
to be medically stable. You do not require wound care, catheterization, G-tube feeding, or administration of 
intravenous or complex medications. You have been educated regarding your medications, and you have not 
been hospitalized recently. You were receiving skilled nursing care for acute on chronic respiratory failure and 
have a stable respiratory status. You are performing a home exercise program. Therefore, the continued home 
health skilled nursing care is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing home health visits (G0299).
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's chance to return home and maintain 
living at home will be reduced If her opportunity to participate in an acute rehabilitation program is denied. The 
Plan denied your request. The Plan says based on Medicare guidelines, the IRF services requested 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 enrollee was admitted for seizure-like activity that was attributed to marijuna use. 
Based on the provided documentation, she does not require any hands-on assistance for bed mobility, and only 
light touch assistance with transfers and minimal assistance with ambulation of 15 feet with a small base quad 
cane. Physical therapy specifically recommended continued therapy sessions only 2-3 times per week upon 
discharge. Therefore, she does not have the intensive, interdisciplinary needs such as those provided at an 
inpatient rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a carotid sinus baroreflex activation 
device and generator 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not standard medical treatment for the enrollee's condition. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is whether the requested authorization for implantation of a Barostim Neo system is 
medically necessary. Baroreflex stimulation devices have been considered potential alternative treatments for 
resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse generator implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator 
delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid 
arteries. In August 2019 the Food and Drug Administration (FDA) approved the system for use in patients with 
refractory heart failure who remain symptomatic despite treatment with guideline-directed medical therapy, are 
NYHA Class III, have an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This 
was based on a clinical study demonstrating improvement in normal daily activities, distance walked, quality of 
life, and improved cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. 
As a result, at this time the Barostim Neo system would not be considered medically reasonable and necessary 
in this patients clinical management. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantation of a carotid sinus baroreflex activation device and generator
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-Plan services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve out-of-Plan services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the requested service is out-of-network, and the 
service could be performed in-network. 
 
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 
out-of-Plan services 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 the enrollee would like reconsideration because the 
services are medically necessary. 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's medical complexity does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care.  There is not a reasonable expectation that the 
enrollee will be able to benefit from the intensive rehabilitation 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: 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 will benefit from an intensive inpatient 
rehab to prevent decline and improve their independence in functional mobility transfers. The Plan denied your 
request. The Plan says the enrollee 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 does not require treatment by multiple therapies. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to continue to pay for skilled nursing facility (SNF) care. 
 You asked the Plan to continue to pay for SNF care. You say that you are requesting more time to transition 
from the Skilled Nursing Facility (SNF) to independent living. The Plan denied your request. The Plan says 
your request does not meet Medicare guidelines because you no longer require skilled services on a daily 
inpatient basis and the continuation of SNF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to continue to pay for skilled nursing facility (SNF) care.