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

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services after August 26, 2020.
You asked the Plan to pre-approve the continuation of SNF services after August 26, 2020. You say that you were given to much chemotherapy, which almost killed you and you do not feel strong enough to return home. The Plan denied your request. The Plan says you do not meet CMS guidelines for continuation of SNF services.
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 continuation of SNF services after August 26, 2020. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral and topical medications. You had stable vital signs and your lungs were clear. You had routine colostomy care. Regarding rehabilitation services, you received physical therapy (PT), speech therapy (ST) and occupational therapy (OT) in the SNF. By the dates in question, you were at an independent/modified independent to supervision level with functional mobility including gait to 350 feet with a rolling walker. You required varying assist with activities of daily living. You worked with ST on mild problem solving and moderate memory deficits. You could negotiate 15 stairs with supervision. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis.
As a practical matter, 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 the continuation of SNF services after August 26, 2020. have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services after August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on February 
15, 2020. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you made several calls to 
your primary care physician to get a same-day appointment and were unable to. The Plan denied your request. 
The Plan says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the urgent care services on February 15, 2020. You are asked to pay 
a $55 copayment for the urgent care visit. Your EOC states that enrollees must pay a $55 copayment for 
Medicare-covered urgently needed service visit. 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 
urgent care services provided on February 15, 2020.
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 enrollee is not medically stable for transfer to another 
level of 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 patient 
appears to still require acute care services, however, with additional improvement, he should be able to be 
discharged to a lower level of care in less than 25 days. The patient does not require services at the LTACH 
that are not available at the current 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections coded as 64490, 64492 and 64491. 
 
You asked the Plan to pre-approve the injections. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says that this request is not 
reasonable or necessary as the pain is only for 6 weeks and no supportive documentation of failed conservative 
management. 
 
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 injections. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found The enrollee meets the criteria for repeat RFA.  There is NO requirement to repeat 3 months of 
conservative therapy before repeating an RFA. The requested procedure is medically reasonable and 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 the injections have been met. Therefore, we decided that the Plan has to pre-
approve facet joint injections coded as 64490, 64492 and 64491.  
 
 
 
 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hearing aid evaluation provided on 
January 27, 2020. 
 
You asked the Plan to waive the copayment for a hearing aid evaluation. You say that you shouldn't have a 
copayment for this. The Plan denied your request. The Plan says the correct copayment has been 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 $40 
copayment for hearing services.  
 
You have been asked to pay a $40 copayment for a hearing aid evaluation. The provider who rendered these 
services is not part of the appropriate network; therefore, the correct copayment has been applied. A hearing aid 
evaluation falls within the hearing services 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 a hearing aid evaluation on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have bad balance issues and you have been 
trying to get a shower chair to prevent you from falling while in the shower. You say that you have cancer and 
your legs are weak, which makes it difficult to stand in the shower. You stated that you are afraid of falling and 
you asked the Plan to reconsider providing coverage for the requested item. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the chest (71250). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the enrollee is a former smoker with a tiny 
lung nodule first seen in 2016, shown to be unchanged in 2019.  No further follow-up of this nodule is needed, 
according to 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Computed Tomography (CT) of the chest (71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you broke your leg and are currently receiving 
therapy in the hospital. You say that your wife is unable to care for you at home. The Plan denied your request. 
The Plan says you can safely receive the services you need in other settings. 
 
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 that you do not need IRF level of therapies at the current functional level. Our 
reviewer says that your rehab needs can be met in a lower intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 
You asked the Plan to pre-approve these services. You say that you would like a new continuous positive 
airway pressure (CPAP) device. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a sleep study is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that the 
enrollee has obstructive sleep apnea (OSA) and has been using a bilevel positive airway pressure (BiPAP) 
device since 2011. There is no documentation of compliance from the old device. Without this documentation, 
a repeat sleep study for PAP titration is not supported. The services are therefore not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrelizumab for the enrollee. 
 
You asked the Plan to pre-approve Ocrelizumab. You say that this is medically necessary. The Plan denied 
your request. The Plan says that criteria for coverage is not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary. Medicare rules also say that information must be 
submitted to confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. The case file did not include medical records. Without medical 
records, we cannot make a determination regarding medical necessity and you have not proven that Medicare 
coverage criteria for Ocrelizumab has been met. Based on this information, we decided that Medicare rules for 
coverage of Ocrelizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Ocrelizumab for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan or Supartz.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records do not contain documentation that a diagnosis of right knee osteoarthritis has been confirmed with imaging studies or that the enrollee has failed conservative treatment. The requested Hyalgan or Supartz are therefore not considered safe and effective or reasonable and medically necessary for 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan or Supartz.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee did not meet three separate requirements in the LCD for coverage. 
 
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 monitor. Our reviewer says that the 
requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested monitor would not be considered therapeutic in the setting of an already effectively 
utilizing a manual glucometer daily. There was no indication that using the glucometer was challenged in any 
way based on the notes provided. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs could possibly be met at lower level 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 above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
patient was medically stable with Debility and no evidence of need for supervision by physical medicine and 
rehab physician or need for acute rehab nursing care. Functionally given his current level, though he needs 
physical therapy (PT) and occupational therapy (OT), he/she does not require IRF level of therapies. The 
patient may benefit from further PT and an OT but does not require an intensive therapy program. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says no network inadequacies are seen. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network neurologist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COPD exacerbation 
and acute respiratory failure. 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. The record does support a need for 
physical and occupational therapy but there is no need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF care. 
 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental anesthesia services.
You asked the Plan to pre-approve these services. You say that you need the services for a tooth extraction. The Plan denied your request. The Plan says the services are not a covered 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 pre-approve dental anesthesia services.
Appeal type: Transportation
Decision: Unfavorable

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