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 medical records provided support the 
need for care in a LTACH. The Plan denied your request. The Plan says services can be provided in a lower 
level of care such as a skilled nursing facility (SNF). 
 
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 is a 79-year-old female with myasthenia gravis who was admitted to the 
acute care hospital with dysphagia, thrush, pneumonia, UTI, and respiratory failure, requiring intubation, 
antibiotics, vent support, antifungal medication. Recent notes describe the enrollee is off antibiotics but with new worsening chest x-ray findings and rising leukocytosis as well as still dependent on vent support but 
tolerating weaning. The enrollee appears to be improving with current treatment but is still somewhat unstable 
and should only require short-term additional acute care services that can safely be provided at the current 
facility until more stable and appropriate for transfer. 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 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 28, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crown 
(predominantly base metal) and abutment supported retainer for porcelain/ceramic 
 
You asked the Plan to pre-approve abutment supported porcelain fused to metal crown (predominantly base 
metal) (D6060) and abutment supported retainer for porcelain/ceramic (D6068). You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the dentist's notes/x-rays do not show the 
services are needed for a procedure to place, remove or treat an implant. 
 
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. The Plan covers abutment 
supported porcelain fused to metal crown (predominantly base metal) (D6060) and abutment supported retainer 
for porcelain/ceramic (D6068) when the services are medically necessary and reasonable.   
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 abutment supported porcelain fused to 
metal crown (predominantly base metal) (D6060) and abutment supported retainer for porcelain/ceramic 
(D6068). Our reviewer says that the enrollee does not meet the criteria for the requested services. Our 
physician reviewer found the documentation provided did not show the presence of implant bodies in areas of 
teeth 11, 12, 14 and 30. Our physician reviewer also found that a more detailed treatment plan with proper 
documentation is required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of abutment supported porcelain fused to metal crown (predominantly base metal) 
(D6060) and abutment supported retainer for porcelain/ceramic (D6068) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crown 
(predominantly base metal) and abutment supported retainer for porcelain/ceramic
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 medical needs are complex and meets 
the criteria for IRF admission. The Plan denied your request. The Plan says the IRF services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that without this procedure the enrollee's health will 
decline. The Plan denied your request. The Plan says there remains an absence of clinical studies examining the 
benefits and long-term outcomes to establish the value of this procedure. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes to establish the value of CardioMEMS in patient 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not show the enrollee is able to take part in three 
hours of therapy a day at least five days a week or 15 hours per week: in the hospital and limited by the 
inability to bear weight on your right leg along with left leg weakness. The Plan says services may be provided 
at a lower level of care.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH can provide the multi-
disciplinary approach that would address the enrollee's complex medical issues and comorbidities. The Plan 
denied your request. The Plan says with additional time in the current setting, clinical stability can be ensured 
such that the enrollee can be transferred to the next appropriate 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. 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. Given there are offered alternatives, LTACH 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 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 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 chronic obstructive pulmonary disease (COPD) and 
dysphagia. 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.  
 
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 the SNF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as home with home healthcare. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for inpatient hospital stay and are trying to get the 
enrollee to a SNF for a short time until the enrollee can return home. 
 
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 the enrollee does 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 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require more therapy than home health is 
currently providing. The Plan denied your request. The Plan says you do not meet the requirements for an IRF 
admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation does not support that you would meet 
the criteria for admission to an IRF. You can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic facet joint injection provided on July 11, 2023. 
 
You asked the Plan to pay for a diagnostic facet joint injection. You say that this is medically necessary. The 
Plan denied your request. The Plan says the criteria has not 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 pay for a 2nd diagnostic facet joint injection. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that guidelines do not 
cover facet injections above C2 as the efficacy of C1-C2 is very controversial. Therefore, the procedure was 
not medically reasonable and 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 diagnostic facet joint injection have not been met. Therefore, we decided that 
the Plan does not have to pay for a diagnostic facet joint injection provided on July 11, 2023.
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 require an IRF admission to be able to get 
stronger and walk again. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, but skilled therapies as an outpatient or at a skilled nursing facility may be approved upon request.  
 
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 are deconditioned due to chronic arthritis. You do not require intensive or 
complex rehabilitation. Nor do you require frequent oversight.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on August 16, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the psychotherapy 
provided on August 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS device. 
 
You asked the Plan to pre-approve CardioMEMS device. You say that this service is medically necessary and 
urgently needed by the enrollee. The Plan denied your request. The Plan says this device is currently 
considered unproven and therefore is not considered 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the CardioMEMS device was approved by the Food and Drug Administration 
(FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of 
pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in 
patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved 
ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and 
suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert 
opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there 
remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not 
be considered medically appropriate 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CardioMEMS device.