Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says there are 
multiple in-network providers that can service the enrollee's needs. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wheelchair purchased on December 28, 2019. 
 
You asked the Plan to pay for this wheelchair. You say that this wheelchair should be covered by the Plan. The 
Plan denied your request. The Plan says you did not have prior authorization for a wheelchair and there are no 
medical records submitted to show you met the required coverage criteria for a wheelchair at the time of 
purchase. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that durable medical equipment may require prior authorization. You did not have prior authorization to 
purchase or rent a wheelchair. The appropriate medical records to show a manual wheelchair was necessary in 
the home were not submitted prior to purchase. We found no exception that would require the Plan to pay for 
these items/services. Therefore, we decided that the Plan does not have to pay for a wheelchair purchased on 
December 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional routine transportation trip. 
 
You asked the Plan to pre-approve an additional routine transportation trip. The Plan denied your request. The 
Plan says that this request exceeds your contract benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional routine transportation trip.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) services. 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee's symptoms have typical and atypical 
features of angina pectoris. You say that cardiac risk factors include hypertension, dyslipidemia, and diabetes. 
You say that the enrollee's family history is significant for premature coronary artery disease and vascular 
disease. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of a 
CT scan. The Plan says that the medical records did not indicate that the enrollee has a history of CAD or a 
persistent symptom after a stress test. 
 
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 
requested CT scan is not medically necessary. Our physician reviewer found there is no specific clinical 
rationale for the requested CT scan. 
 
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 computed tomography (CT) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above. 
 
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 patient was admitted for heart bypass surgery. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the record supports a need for physical and occupational therapy, it does not support a need for an 
intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric admission. 
 
You asked the Plan to pre-approve inpatient psychiatric admission. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has 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 inpatient psychiatric admission. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found based upon review of the records provided, you do not meet the criteria for 
continued acute inpatient mental health treatment for the dates in question of September 9, 2020 forward as you 
were not shown to be a danger to yourself or others. You were not showing any visual hallucinations although 
slight auditory hallucination, delusions and were cooperative/compliant with treatment while not showing any 
threats to the safety of yourself or others. 
 
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 psychiatric admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that your current wheelchair's motor 
broke. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because 
you do not have a qualifying diagnosis for a Group 3 power wheelchair and a Group 2 power wheelchair or 
power operated vehicle may meet your needs. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair with accessories.
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 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 Medicare pays for care in a SNF when the four factors 
listed above 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 daily 
skilled services are not necessary. Our physician reviewer found you are now mostly modified 
independent/supervised for all care. You have no complex wound care needs, or IV medication requirements. 
There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care 
(including home health care services). Your vital signs are stable. SNF 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 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above. 
 
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 the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan (J9312). 
 
You asked the Plan to pre-approve Rituxan. You say that Rituxan is medically necessary for treatment of the 
enrollee's condition. The Plan denied your request. The Plan says Rituxan is not supported in this case. 
 
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 Rituxan. Our reviewer says that the 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. Our physician reviewer found Rituxan is not approved by the Food and Drug 
Administration (FDA) for treating the enrollee's condition. Rituxan is also not supported in this case by 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 Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan (J9312).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services can be safely received in another setting, such as an inpatient 
rehab facility, a skilled nursing facility, or the current hospital. 
 
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 currently undergoing treatment at an ACH for sacral ulcers. The 
enrollee has undergone surgical debridement and is receiving ongoing wound care. The enrollee is not 
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. 
 
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 admission to a long term acute care hospital (LTACH)
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's continued care could be better provided in an outpatient, 
skilled nursing facility or long term care facility setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for left below knee 
amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the record supports a need for physical and occupational 
therapy, it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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 for the enrollee.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above. 
 
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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, skin and oxygen (O2) care, and daily therapy can be provided at a SNF. The member 
is mostly MODERATE/MIN assist for functional transfers and activities of daily living (ADL's) and a less 
intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and 
predicted period. An IRF intensity is not warranted. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the therapeutic, prophylactic, or diagnostic 
injection (96375), chemotherapy administration (96413, 96415), ocrelizumab injection (J2350), 
diphenhydramine injection (J1200), and the methylprednisolone injection (J2930) provided on March 6, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance 
has been applied correctly to the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for in-network Medicare Part B covered drugs and Chemotherapy drugs provided.  
 
The enrollee has been asked to pay $6,534.51($36,506.84 allowed amount x 20% coinsurance) for the in-
network Medicare Part B covered drugs and Chemotherapy drugs provided, which is less than the applicable 
coinsurance. This means that the enrollee has been asked to pay the correct amount based on the contract with 
the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.  
Therefore, we decided that the Plan does not have to waive the coinsurance the therapeutic, prophylactic, or 
diagnostic injection (96375), chemotherapy administration (96413, 96415), ocrelizumab injection (J2350), 
diphenhydramine injection (J1200), and the methylprednisolone injection (J2930) provided on March 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
February 19, 2020. 
 
You asked the Plan to pay for the services. You say that there was no oral surgeon in the area to do biopsy that 
took Medicare patients. The Plan denied your request. The Plan says there is a contracted provider available 
who could have provided the services in question. 
 
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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-network 
provider on February 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $275 copayment charged for ambulance transport 
provided on April 14, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $275 
copayment for ambulance transport. You have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the $275 copayment charged for ambulance 
transport provided on April 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 10, 2020 to 
March 24, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claims were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with a valid 
HIPPS code. 
 
We looked at the file and Medicare rules. The file shows that the claims for these services were not billed with 
a valid HIPPS code. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from March 10, 2020 to March 24, 2020.