Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says based on 
Medicare guidelines, the enrollee does not meet the requirements for approval of a 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 that long term acute care hospitals are certified as acute care hospitals and, in general, 
LTACHs do not provide clinical services that are materially different than those of short-term acute care 
hospitals. In this case, ongoing care needs include tracheostomy care, pulmonary toilet, surveillance laboratory 
studies, tube feedings, wound care, and therapy services. The documentation does not support that the enrollee 
in this case requires services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no required medical services identified that are available at the LTACH that 
are not available at the current health care setting being offered by the health plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that you still need work on your hips and legs. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
the requested additional therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific 
and effective therapy for your condition. You have had prior therapy for your condition and it does not appear 
that you require the ongoing unique skills of a professional therapist to safely and effectively provide treatment, 
that the services can be safely and effectively performed only by a therapist, or under the supervision of a 
therapist. You were authorized additional sessions to review an independent exercise program and ensure 
safety. The specialized skill, knowledge, and judgment of a qualified therapist is not required to establish, 
design, and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further 
deterioration.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy administration (96413, 96415) and Inflectra 
(Q5103) provided on January 21, 2020. 
 
You asked the Plan to pay for chemotherapy administration and Inflectra. You say that this should be covered. 
The Plan denied your request. The Plan says these codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 96413, 96415, and Q5103 are not supported in the medical record. Specifically, while 
the submitted medical records for this date of service show these services were planned, there is no 
documentation of them being performed. Based on this information, we decided that Medicare rules for 
coverage of chemotherapy administration and Inflectra have not been met. Therefore, we decided that the Plan 
does not have to pay for chemotherapy administration (96413, 96415) and Inflectra (Q5103) provided on 
January 21, 2020.
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. The Plan denied your request. The Plan says the IRF services you 
are requesting 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 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. Our 
reviewer found that specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative 
services and regular physician evaluation. Our physician reviewer also found that the enrollee's 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: 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 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 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 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. 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 does document a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. 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. 
 
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99285) from 
June 10 to June 12, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were admitted to a 
hospital within the same healthcare organization as a result of the initial service provided in the emergency 
room. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 a $120 
copayment for emergency services. The contract also says that you do not pay the emergency room visit cost-
share if admitted to the hospital within 24 hours for the same condition. 
 
In this case, however, you were transferred and admitted to a different hospital than where the emergency room 
visit took place. Therefore, you have been asked to pay a $120 copayment for an emergency room visit. An 
emergency room visit falls within the "Emergency care" benefit category. This means that 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 copayment for an emergency room visit (99285) from June 10 to June 12, 2020.
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 do not require skilled nursing or therapy 
services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter and lubricant provided on May 29, 2020. 
 
You asked the Plan to pay for the provided services. You say that the items were shipped in accordance with 
the guidelines. The Plan denied your request. The Plan says the billing exceeds the maximum allowable units. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The records show that the enrollee received a 6-month supply of code 
A4402 by another provider in March 2020. The Plan paid for a 1-month supply for code A4351, in addition to 
the 2-month supply provided by another provider in March 2020. The additional supplies exceed the allowable 
amount for the items at issue. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the catheter and lubricant provided on 
May 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that step 
therapy, as outlined by the Plan requires a trial of Orthovisc. The documentation does not discuss a trial of 
Orthovisc. Our physician reviewer found the documentation does not outline contraindications or reasons 
orthovisc was not considered. Without the support of the documentation, step therapy exception criteria have 
not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953) and personal protective 
equipment (PPE) (D1999) provided on June 17, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are aware that the services you received are 
not listed in the Payment Charge Schedule. You say that you believe that they should be covered. You say that 
you take medications that have negatively impacted your teeth. You also say that you have a dry mouth 
condition that has led to serious medical-dental issues. The Plan denied your request. The Plan says bone 
replacement graft is not listed as a covered service. The Plan also says that PPE is not listed as a covered 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft (D7953) and personal protective equipment (PPE) (D1999) provided on June 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five home health physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not verify progressive functional improvement. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the requested additional therapy is not generally accepted as specific and 
effective therapy for your condition. You have had extensive therapy for your condition, and it does not appear 
that you require the ongoing unique skills of a professional therapist to safely and effectively provide treatment, 
or that the services can be safely and effectively performed only by a therapist, or under the supervision of a 
therapist. You have been authorized additional sessions to review an independent exercise program and ensure 
safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve five home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi electric hospital bed with side rails and mattress 
(E0260).
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the records provides should 
support medical necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria for a semi-electric bed. However the records do support that the enrollee 
meets the criteria for a fixed height or variable height hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi electric hospital bed with side rails 
and mattress. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found The documentation does not clearly reveal that patient's 
condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed 
in other ways is not feasible. The documentation does not support a need for an immediate or frequent change 
in body position or special attachments that cannot be fixed on an ordinary bed. The head of the bed does not 
need to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary 
disease, or problems with aspiration. The request for a semi-electric hospital bed is not medically necessary for 
this enrollee 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of semi electric hospital bed with side rails and mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve semi electric hospital bed with side rails and 
mattress (E0260).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiography for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a re-evaluation is not recommended until every 3 to 5 years. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a history of non-ischemic cardiomyopathy which has normalized on medical therapy, 
atrial fibrillation and mild-moderate mitral insufficiency. She is also on flecanide therapy for PAF. Given the 
combination of moderate mitral insufficiency and the need for continued flecanide therapy, reassessment of LV 
function is reasonable and medically necessary as flecanide would be contraindicated and would be 
discontinued if the ejection fraction decreases. In addition, repeat echocardiography in patients with moderate 
mitral insufficiency is reasonable and considered medically necessary every 1-2 years based on AHA/ACC 
appropriate use criteria. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a transthoracic echocardiography for the enrollee.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and wheelchair 
lights (K0108). 
 
You asked the Plan to pre-approve the power seat elevation system and wheelchair lights. You say that you 
would like reconsideration because this equipment is medically necessary. The Plan denied your request. The 
Plan says these accessories are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and wheelchair lights 
(K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the chiropractic services provided from April 8, 
2020, to April 23, 2020. 
 
You asked the Plan to reimburse you for the chiropractic services. You say that you want the Plan to reimburse 
you for the chiropractic services. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
We looked at this physician's review, the file, and Medicare rules. These services are not a covered benefit. The 
services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Based on this information, we decided that Medicare rules for 
coverage of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the chiropractic services provided from April 8, 2020, to April 23, 2020.