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

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not require an intensive level of therapy with physician 
oversight. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollee's condition is in fact complex and fragile. There is every reason to expect that she will 
participate in and benefit from services to include at minimum physical therapy, occupational therapy, 
respiratory therapy, physician oversight of post-op risks, polypharmacy, and case manager coordination of any 
additional services that might be needed to make a sustainable return home and avoid preventable readmissions 
to the acute hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 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 as the 
enrollee meets the full criteria for an inpatient rehabilitation stay. The Plan denied your request. The Plan says 
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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health admission. 
 
You asked the Plan to pre-approve inpatient behavioral health admission. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 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 inpatient behavioral health admission. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon 
review of the records provided this enrollee does not meet criteria for acute inpatient mental 
health/detoxification treatment as this enrollee was not shown to be a danger to himself or others. There were 
no auditory or visual hallucinations. He is noted to be cooperative and compliant with treatment while not 
showing any aggressive behaviors. He was not showing any signs of withdrawal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient behavioral health admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behavioral health admission.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee's memory is in decline and there is a 
family history of AD. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the record indicates that the enrollee 
has memory loss and ataxia thought to be due to Alzheimer's disease. The records provided does not establish 
that the enrollee meets the diagnostic criteria of both Alzheimer's disease and frontotemporal dementia or that 
the examination is being requested in the context of a clinical trial. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
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 LTACH services are medically 
necessary. 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 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 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 she is not currently 
receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the requested revascularization (37224 and 37220) with 
angiography (75710) and moderate sedation (99152). 
 
You asked the Plan to pre-approve the requested revascularization (37224 and 37220) with angiography 
(75710) and moderate sedation (99152). You say that the requested revascularization (37224 and 37220) with 
angiography (75710) and moderate sedation (99152) is medically necessary. The Plan denied your request. The 
Plan says that the requested revascularization (37224 and 37220) with angiography (75710) and moderate 
sedation (99152) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 requested revascularization (37224 
and 37220) with angiography (75710) and moderate sedation (99152). Our reviewer says that the requested 
revascularization (37224 and 37220) with angiography (75710) and moderate sedation (99152) is medically 
necessary. Our physician reviewer found the documentation supports the medical necessity of the procedures in 
question. The enrollee requires placement of a Transcatheter aortic valve replacement (TAVR). This is a large 
device, generally placed via the femoral artery that must have a pathway wide and pliable enough to safely 
navigate to the aortic valve where it is then deployed. If the iliac artery (in this case the external iliac artery) is 
relatively small and calcified, the device might tear the artery in efforts to pass within it potentially resulting in 
catastrophic bleeding. This can be the case even if the computed tomography (CT) scan report does not 
describe an occlusive lesion. The planed shockwave angioplasty is designed to soften up the calcium in the 
wall of the artery to make it more expandable so the device can pass safely. This medically necessary 
indication is not generally on the list of classic indications for coverage.  The procedure is reasonable and 
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 requested revascularization (37224 and 37220) with angiography (75710) 
and moderate sedation (99152) have been met. Therefore, we decided that the Plan has to pre-approve the 
requested revascularization (37224 and 37220) with angiography (75710) and moderate sedation (99152).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 5th bilateral interlaminar/caudal epidural steroid 
injection at L5-S1.  
 You asked the Plan to pre-approve the epidural steroid injection. You say that your physician recommends you 
receive treatment six times annually. The Plan denied your request. The Plan says you do not meet the medical 
necessity criteria for epidural steroid injections for pain management.  
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 epidural steroid injection. Our 
reviewer says that the requested injection is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the rules limit the number of epidural steroid injections to four in a rolling 12 
month period. This request exceeds that number and therefore, the request is deemed 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 the epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a 5th bilateral interlaminar/caudal epidural steroid injection at L5-S1.
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 you need to get stronger and get physical therapy 
before you can go home. The Plan denied your request. The Plan says the record shows that you do not meet 
Medicare guidelines for services in a skilled nursing facility.  
 
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 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. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, custodial and intermittent, can 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. You say that single agent immunotherapy is the safest treatment 
with the highest chance of efficacy for the enrollee. The Plan denied your request. The Plan says Keytruda 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 
Keytruda is not medically necessary. Our physician reviewer found that there is no role for adjuvant Keytruda 
in non-metastatic disease despite microsatellite instability.  
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 Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a CardioMEMS device. 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 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 enrollees 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289).
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 since you had a stroke you have had forgetfulness, 
and you walk into walls sometimes and need to be in a skilled nursing facility. You say that you are a diabetic 
and your sugar is out of control and you depend on your nurse for assistance The Plan denied your request. The 
Plan says the requested skilled nursing and/or skilled rehabilitation services do not meet the Medicare coverage 
criteria. 
 
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 clinical documentation shows that you have functional impairments and 
active medical comorbidities thus would be expected to require assessment by skilled therapy and skilled 
nursing. The clinical documentation does not completely specify functional impairments and does not provide 
clinical rational for medical necessity of daily skilled therapies. The clinical documentation does not specify 
any daily skilled nursing needs thus documentation does not support daily skilled services. From a practical 
standpoint, the clinical documentation does not support daily skilled services on an inpatient basis in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 the services are medically necessary for the 
enrollee's functional deficits as well as their multiple comorbidities. 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, including either 
physical therapy or occupational therapy, 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. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 Kerecis Omega 3 skin substitute and associated 
application of the product (15275 and Q4158). 
 
You asked the Plan to pre-approve Kerecis Omega 3 skin substitute and associated application of the product 
(15275 and Q4158). You say that the requested Kerecis Omega 3 skin substitute and associated application of 
the product is medically necessary.  The Plan denied your request. The Plan says the requested Kerecis Omega 
3 skin substitute and associated application of the product 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 Kerecis Omega 3 skin substitute and 
associated application of the product (15275 and Q4158). Our reviewer says that the requested Kerecis Omega 
3 skin substitute and associated application of the product is not medically necessary.   Our physician reviewer found a skin substitute is not medically necessary for treatment of this enrollee. This is 
not a standard 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 Kerecis Omega 3 skin substitute and associated application of the product 
(15275 and Q4158) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Kerecis Omega 3 skin substitute and associated application of the product (15275 and Q4158).