Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies billed to the enrollee from August 19, 2020, to 
August 25, 2020 under codes J1569, A4221 and A4222. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice 
to indicate the specific supplies sent and/or proof of delivery. In addition, the tracking Id submitted do not 
describe the item being delivered. Therefore, the billed supply coded cannot be verified. The Plan notes that  
multiple attempts were made to contact the provider for additional information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. The record does not contain a valid proof of delivery and itemized 
identification of what was shipped.  The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
supplies billed to the enrollee from August 19, 2020, to August 25, 2020 under codes J1569, A4221 and 
A4222.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injections. 
 
You asked the Plan to pre-approve sacroiliac joint injections. You say that the requested sacroiliac joint 
injections are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested sacroiliac joint injections. 
 
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 sacroiliac joint injections. Our reviewer 
says that the enrollee does not meet criteria for the requested sacroiliac joint injections. Our physician reviewer 
found the enrollee has chronic low back pain. She takes Gabapentin, Baclofen and Duloxetine for pain. She had 
Left SI joint injection in Sept 2019 with 3 weeks of relief and Right SI joint injection in May 2019 with mild 
pain relief for 3 weeks. There is no documentation of physical exam findings of SI joint dysfunction and no 
imaging reports regarding the SI joints. There is a lack of documentation to support repeat SI joint injection.  
Therefore, at this time, the request is deemed not medically reasonable or 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 sacroiliac joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another 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 in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
rhabdomyolysis after a fall and a urinary tract infection. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do 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 you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of 
SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for continued SNF care. 
 
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 continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found this 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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that 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 shortness of breath, nausea, anorexia and weakness. Her 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 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. 
 
Additionally, 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit, as it is considered a convenience item that is not primarily 
medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says 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 there is no evidence that the enrollee requires services that are not currently available. 
There is no medical reason to transfer the enrollee from the current 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dofetilide capsule 125mcg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug is not covered under the medical benefit plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dofetilide capsule 125mcg 
for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you need to go to the LTACH because a skilled nursing facility cannot provide antibiotics. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.
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 you appear to be stable and only require short-term additional acute care services that can be safely received at the current facility. There are no services at the LTACH that you require that are not already available at the current hospital. Transfer to a lower level of care may be considered soon when your treatment has completed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care, for the enrollee. 
 
You asked the Plan to pre-approve SNF 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 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 daily 
skilled services are not necessary. Our physician reviewer found this 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's wound care is 
not complex, and wounds are healing. 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 SNF setting. We looked at this 
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve 
SNF care, for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of inpatient 
skilled nursing facility care. 
 
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 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you do not 
require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter, you do 
not require the necessary services on an inpatient basis, only in a skilled nursing facility setting. Services in the 
home with home health or in a long-term care facility on a part time basis appear appropriate in this case. 
 
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 inpatient skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on December 7, 
2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you are covered for a preventive 
ultrasound. The Plan denied your request. The Plan says the copayment applied correctly. 
 
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 $60 per 
day for an ultrasound. 
 
You have been asked to pay a $60 copayment for the ultrasound. The ultrasound falls within the "Outpatient 
diagnostic tests and therapeutic services and supplies" benefit category. The ultrasound is considered a 
diagnostic service. 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 ultrasound provided on 
December 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Supartz FX injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan's preferred viscosupplements are Orthovisc and Monovisc, which don't require 
authorization. 
 
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 the injection. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the plan requires a 
trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, you have not tried 
and failed the required drugs. There is no documentation provided indicating that the the plan?s required drugs 
would likely be less effective and/or likely have adverse effects for the 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Supartz FX injection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on August 7, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
you must receive your care from a network provider. In most cases, care you receive from an out-of-network 
provider (a provider who is not part of our plan's network) will not be covered. If you need medical care that 
Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this 
care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to 
seeking care.  
 
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 did not pre-approve the 
diagnostic radiology services. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for diagnostic radiology services provided on 
August 7, 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 unable to move around and require 24-hour 
care. The Plan denied your request. The Plan says the denial of authorization for IRF care 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 the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 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 you 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and the 
cone beam computed tomography (CT) capture and interpretation. 
 
You asked the Plan to pay for the periodontal evaluation and the cone beam CT capture. You say that the 
requested services should be covered. The Plan denied your request. The Plan says these services are not 
covered under your supplemental benefit. 
 
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 
comprehensive periodontal evaluation (D0180) and the cone beam computed tomography (CT) capture and 
interpretation.