Persius/hicric huggingface dataset:
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 these services are medically necessary. 
The Plan denied your request. The Plan says that you can safely receive this care in another setting. 
 
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. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. You are receiving all required services in the current acute care setting. There are no services 
available at the LTACH that you require that are not available at the health care setting being offered by the 
health plan. The health plan has approved ongoing care in the current acute care setting. Our physician 
reviewer found that your condition does not meet Medicare criteria for LTACH services. 
 
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 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 needs. 
 
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 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 does not 
have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter, this enrollee does not require the necessary services 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: 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 the enrollee is at a custodial/maintenance level of care. 
 
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 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 does not 
have complex wound care. He has his ileostomy changed twice weekly. He has had eduation and verbalized 
understanding of ileostomy care. His wound care is not comples. There is no other ongoing SNF level SN need. 
The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge 
and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment only in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a 
combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require 
the necessary services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not considered medically necessary for the post-operative treatment of head and 
neck cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found proton therapy is not an accepted standard of care for routine practice for typical locally advanced head 
and neck cancers. Proton therapy cases are challenging since proton therapy will invariably reduce normal 
tissue exposure - but not always in a clinically meaningful way. What is needed to establish necessity is to 
show that proton therapy will result in a clinically meaningful benefit by reducing normal tissue exposure 
below threshold levels (or improving target coverage unachievable with IMRT). Notably, there is no provided 
plan comparisons in the case file to provide a plausible dosimetric rationale for the need of proton therapy. Its 
potential benefit over non-proton based radiation is an investigational question. Thus, proton therapy is not 
necessary as it would not meet ASTRO or NCCN criteria and therefore would not be -when used for routine 
cases - furnished in accordance with accepted standards 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 the therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy 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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the documentation received fails to indicate that the member 
requires daily medical practitioner assessment or intervention and at least six and a half hours per day of skilled 
nursing care. 
 
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. The short-
term acute care hospital can provide for all the patient's present inpatient care needs and the patient is receiving 
an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is 
appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation 
facility, a sub-acute rehabilitation facility or a skilled nursing facility. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your appropriate therapy needs are not precluded in an alternate level of 
care such as skilled nursing facility. 
 
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. 
Records do not indicate that there are significant, or complex medical/nursing issues that could not be 
addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, 
and daily therapy can be provided at a lower level of care. You are mostly total assist for functional transfers 
and lower body activities of daily living and a less intensive, longer duration of therapy may be more 
appropriate. It is not clear that you would be able to fully benefit and/or participate in an IRF level of care. Our 
physician reviewer found that your 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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 routine transportation trips. 
 
You asked the Plan to pre-approve these services. You say that you had hip surgery and need transportation. 
The Plan denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 20 routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF care. You say that the enrollee is still not able to care for herself 
and should be allowed to go to a SNF. The Plan denied your request. The Plan says the enrollee is receiving 
adequate care in the IRF and does not need to transfer to a SNF at this time. 
 
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 the SNF care. Our reviewer says that 
transfer to a different facility is not medically necessary at this time. Our physician reviewer found the enrollee 
is a 72-year-old female with a past medical history of hypertension, hyperlipidemia and osteoarthritis who has 
been an inpatient in a rehabilitation facility since 08/31/2020 for treatment after a stroke. She is working with 
physical and occupational therapy. She is walking 150 feet with a walker and is supervision or contact guard 
assist for transfers and activities of daily living. She has ongoing issues with back pain, electrolyte disturbance 
and a recent urinary tract infection. Transfer to a skilled nursing facility for skilled nursing and therapy services 
is requested. 
 
At this time, the enrollee continues to require daily skilled nursing and therapy services. However, she is 
receiving this care in the present IRF stay and transfer to a lower level of care for continued services does not 
appear to be warranted. Services in the inpatient rehabilitation facility appear appropriate until she is stable to 
transfer to home with home health services. 
 
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 care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotic devices (L0650, L1851, L2397) provided March 23, 
2020. 
 
You asked the Plan to pay for the orthotic devices. You say that the items were medically necessary. The Plan 
denied your request. The Plan says valid proof of delivery was not provided. 
 
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 for the supplies provided in this case. The provided 
delivery ticket is not itemized and shows the items were shipped on March 5, 2020 and delivered on March 7, 
2020. The delivery date does not match the date of service on the claim. 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 orthotic devices (L0650, L1851, L2397) provided March 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment charged to the enrollee for ambulance transport 
on February 22, 2020. 
 
You asked the Plan to waive this cost share for the enrollee.  You say that you do not believe this bill is correct. 
The Plan denied your request. The Plan says this claim was processed based on the Plan contract agreement. 
However, the Plan informed Maximus that they have now removed the application of the deductible leaving 
only the ambulance transport copayment due. 
 
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 enrollees contract with the Plan clearly says that enrollees 
must pay $270 for copayment for each one-way ambulance transport. 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 
deductible and copayment charged to the enrollee for ambulance transport on February 22, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the durable medical equipment (L3170) provided on March 16, 2020. 
 
You asked the Plan to pay for the durable medical equipment (L3170). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the durable medical equipment (L3170) by the provider. The provider is a 
contract provider. The file does not show that the plan provided notice that the durable medical equipment 
(L3170) would not be covered. Under Medicare rules, this means the durable medical equipment (L3170) is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the durable medical 
equipment (L3170) provided on March 16, 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: 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 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 required maximum assistance for bathing. The enrollee is able to walk 50 
feet with a walker. The enrollee required minimal to moderate assistance with transfers and most activities of 
daily living. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided from February 2, 
2020 to February 20, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the evaluation did not take 
place at a qualifying originating site per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the durable medical 
equipment provided from February 2, 2020 to February 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. The Plan denied your request. The Plan says you 
do not have any skilled nursing or therapy needs. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our 
physician reviewer found that you forget to take your medications and need assistance with activities of daily 
living. There is no documentation that you have any skilled nursing or therapy needs. There is no 
documentation that the home health aide services are reasonable and necessary for the treatment of illness or 
injury by a skilled professional staff. Therefore, home health aide services are not 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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.