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

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee has dementia and needs to get 
her strength back in order to go home safely. The Plan denied your request. The Plan says SNF services are not 
medically necessary based on 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 the SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found the enrollee does not 
require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional 
nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The 
enrollee has no complex wound care or other skilled nursing needs. The enrollee's functional level does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist 
required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled 
nursing or therapy services are not required on a "daily basis" or as a practical matter on 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve a power wheelchair. You say that this is medically necessary. The Plan 
denied your request. The Plan says that there is not enough room in your camper to move around in all the 
rooms with a power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle (POV) can be covered 
if the beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the POV that is provided. 
 
We looked at the file and Medicare rules. The mobility evaluation in the case file indicates your home 
environment does not have enough room for a power wheelchair. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair for the enrollee.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the physical therapy (PT) services you received on 
September 14, 2020. 
 
You asked the Plan to waive the copayment for the PT services. You say that you had reached your out-of-
pocket maximum prior to these services, so no copayment should apply. The Plan denied your request. The 
Plan says that this copayment was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has failed to provide any spreadsheets, complete 
Explanations of Benefits, or any other documentation showing how much you had paid towards your out-of-
pocket maximum prior to receiving the PT services in question.  Without this information, we cannot determine 
whether you had met this $2,800 amount or not.  It is the Plan's obligation to provide sufficient supporting 
documentation to justify its denial.  They have failed to do so in this case. Therefore, we decided that the Plan 
has to waive the copayment for the physical therapy (PT) services you received on September 14, 2020.  
 
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 waive the $114.73 cost share applied to the deductible for an orthosis 
provided to the enrollee on April 1, 2020.  
 
You asked the Plan to waive this cost share. You say that you do not believe this is correct. The Plan denied 
your request. The Plan says the deductible was not satisfied at the time the orthosis was provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The  
contract with the Plan says that there is $250 deductible for 2020. This deductible applies to durable medical 
equipment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $250 
deductible. This cost sharing is a contractual obligation that had not been met at the time this equipment was 
received. Therefore, we decided that the Plan does not have to waive the $114.73 cost share applied to the 
deductible for an orthosis provided to the enrollee on April 1, 2020.
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 would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee required minimal assistance for rolling. The enrollee required moderate
assistance times two to lie down. The documentation does not support that the enrollee requires an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not
support that the enrollee requires an intensive rehabilitation therapy program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 
enrollee does not meet criteria for IRF admission. 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 enrollee was admitted for congestive heart failure, atrial 
fibrillation, and acute respiratory failure. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in 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. 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 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 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 enrollee 
was admitted for weakness, left leg swelling, uncontrolled hypertension and a urinary tract infection. Medical 
problems are stable. 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. Medically necessary care can be 
provided in a different level of care. 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 IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ground mileage and ambulance service provided on April 
26, 2020. 
 
You asked the Plan to pay for the ground mileage and ambulance service. You say that the enrollee was still 
alive on this date of service. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal 
condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ground mileage and ambulance service provided on April 
26, 2020.
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 would like reconsideration because the IRF 
services are medically necessary. The Plan denied your request. The Plan says the member's needs may be met 
in 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 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no skilled nursing needs. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no 
complex wound care or other skilled nursing need. The enrollee's functional level does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy 
services are not required on a "daily basis" or as a practical matter on 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission you 
received from March 10, 2020, to March 17, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you went to the 
emergency room because you needed to go to the psych ward but no beds were available due to COVID-19.  
You were instead admitted to the hospital.  You later went to a psychiatric hospital on March 17, 2020. You 
feel as though the copayments for these two stays should be combined. The Plan denied your request. The Plan 
says inpatient acute hospital admissions and psychiatric hospital admissions are in separate benefit categories, 
so two separate admission copayments were charged appropriately. 
 
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 $200 
copayment for each admission to an acute care hospital.  
 
Records show that you were admitted to an acute inpatient hospital on March 10, 2020 via the emergency room 
due to chest pain and shortness of breath.  The medical records indicate that once you were medically stable, 
you would be discharged from the acute inpatient hospital and transferred to an inpatient psychiatric facility for 
admission. The records show that you were discharged from the acute care facility on March 17, 2020, and you 
entered the inpatient psychiatric facility later that day. You have been asked to pay a $200 copayment for the 
acute inpatient hospital admission. Your Evidence of Coverage states that this copayment is due for each 
admission and admissions to an inpatient psychiatric facility require a separate copayment. 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 the inpatient hospital admission you received from March 10, 2020, 
to March 17, 2020.
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 appealing this denial. The Plan denied your
request. The Plan says the denial of authorization for IRF service is correct.
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 do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. Your care
needs can be met at a lower level of care such as skilled nursing facility or sub-acute rehabilitation.
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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve chemotherapy (Leucovorin calcium, injection, per 50 milligrams), 
J9190 (Fluorouracil injection), J9206 (Irinotecan injection), and J9303 (Panitumumab injection). 
 
You asked the Plan to pre-approve chemotherapy. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the requested drug 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 chemotherapy. Our reviewer says that 
the documentation supports that the requested drugs are medically reasonable and necessary. Our physician 
reviewer found treatment of enrollees with wild-type RAS (defined as wild-type in both KRAS and NRAS as 
determined by an approved test) metastatic colorectal cancer (mCRC), either as first-line therapy in 
combination with FOLFOX (fluorouracil, leucovorin, and oxaliplatin) or as a single agent following disease 
progression after prior treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-containing chemotherapy. 
The enrollee is KRA/NRAS wild-type. The requested use of these drugs are FDA-approved for the enrollee's 
diagnosis. Therefore, the enrollee meets criteria for the requested drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chemotherapy have been met. Therefore, we decided that the Plan has to pre-
approve chemotherapy (Leucovorin calcium, injection, per 50 milligrams), J9190 (Fluorouracil injection), 
J9206 (Irinotecan injection), and J9303 (Panitumumab injection).  
 
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 would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for a stroke. The enrollee's medical problems are stable. 
The documentation does not support that the enrollee requires an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires 
an intensive rehabilitation therapy program. 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 inpatient rehabilitation facility (IRF) admission and services.