Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient mental health care provided from March 23, 
2019, to March 25, 2019. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the services were 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 pay for the inpatient care. Our reviewer says that the 
requested inpatient mental health care was not medically reasonable and necessary. Our physician reviewer 
found that it was not expected this enrollee would improve in a reasonable period of time as he did not have 
dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any 
behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, 
perceptual disturbance including delusions, auditory or visual hallucinations. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient mental health care provided from March 23, 2019, to March 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozurdex.
You asked the Plan to pre-approve Ozurdex. You say that the requested Ozurdex is medically necessary. The
Plan denied your request. The Plan says the requested Ozurdex is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved
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 Ozurdex. Our reviewer says that the
requested Ozurdex is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of
Retinal edema in the right eye, and hypertensive retinopathy bilaterally. Ozurdex is FDA-approved for the
treatment of diabetic macular edema, retinal vein occlusion, and posterior segment uveitis. The documentation
does not support that Ozurdex is reasonably expected to be safe and effective, and otherwise reasonable and
necessary for the enrollee 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 Ozurdex have not been met. Therefore, we decided that the Plan does not have
to pre-approve Ozurdex.
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 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 
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 management of congestive heart 
failure and infected chronic stasis ulcerations. Medical problems are stable. A PICC line is in place for 
completion of a 2 week course of IV antibiotics. 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 the need for 
physical and occupational therapy, it does not support the need for an intensive rehabilitation program. There is 
not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute 
care on 8/17/20 to 8/21/20 due to pneumonia and altered mental status. From a nursing perspective, the enrollee 
received oral and inhaled medications. The enrollee had stable vital signs.  He was treated with Sinemet. He 
had PleurX catheters which were drained twice weekly.  He used oxygen via nasal cannula. Regarding 
rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital.  
The enrollee was dependent for functional mobility.  The enrollee required varying assist with activities of 
daily living. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 admission to a SNF 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits (97162, 97110) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy visits to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria has not been met. 
 
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 
physical therapy visits (97162, 97110) to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that your 
functional status or activity tolerance requires an 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hysteroscopy provided on November 8, 
2019. 
 
You asked the Plan to waive the copayment for a hysteroscopy. You say that you had no choice of where to 
have the procedure done. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct amount. 
 
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 $100 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $100 copayment for a hysteroscopy. A hysteroscopy falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 hysteroscopy provided on November 8, 2019.
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 records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the records show the enrollee does not need and is not able to 
take part in three hours of therapy for at least five days a week. and does not need to be seen by a rehab doctor 
at least three times a week. The Plan says that the enrollee does not need an intensive team for care. The Plan 
says that the enrollee can safely receive the care needed 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 above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires an 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C intravenous immune globulin (IVIG) 
injections to be provided at the hospital. 
 
You asked the Plan to pre-approve the IVIG treatments. You say that the enrollee would benefit from this 
treatment. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the IVIG treatments. Our reviewer says 
that the requested IVIG treatments are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the member's reported diagnosis is of an autoimmune autonomic neuropathy. He has 
been prescribed IVIG for this condition. IVIG is not currently FDA approved for use in this condition, nor is it 
readily supported within the Medicare Accepted Compendia for use in this indication. The literature on the 
proposed course of treatment primarily consists of case reports and case series from single institutions. There 
have yet to be any well designed clinical studies completed that formally evaluate what (if any) role/benefit the 
proposed therapy has in the member's diagnosis. Consequently, it cannot be said that the use of IVIG would be 
reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the IVIG treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Gamunex-C intravenous immune globulin (IVIG) injections to be provided at the 
hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested out of 
network provider. The Plan denied your request. The Plan says this service can be provided in network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 provider at 
issue in this case is not a network provider with the Plan. 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 out of network providers. Our physician reviewer found the plan's denial medically justified on the 
basis that it is offering adequate care to meet your medical needs. There is nothing unique about your condition 
that makes it medically necessary for you to see the requested out-of-network provider. The Plan has shown 
that they have in-network providers who meet the Standards of Care required for treatment of your condition.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of out of network providers have not been met. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve out of network providers. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record
supports the need for physical and occupational therapy, it does not support the need for an intensive
rehabilitation program. 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: 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 do not believe that the skilled nursing facility will be able to adequately manage your pain to allow for you to progress in therapy. The Plan denied your request. The Plan says there is no documented need for intensive therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient's functional status requires an 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stay at a skilled nursing facility from
April 11 to April 30, 2019.
You asked the Plan to waive the copayment for a stay at a skilled nursing facility. You say that a representative
of the skilled nursing facility stated that an extension to your stay was approved. The Plan denied your request.
The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160
copayment per day for days 21-100 of your stay at a skilled nursing facility.
In this case, you stayed at a skilled nursing facility from March 22 to April 8, 2019. You were then readmitted
from April 11 to April 30, 2019. You have been asked to pay a $2,720 copayment for your stay at a skilled
nursing facility. This equals $0 for the first 20 days within a benefit period and $160 per day for the remaining
17 days. A stay at a skilled nursing facility falls within the skilled nursing facility care benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for a stay at a skilled nursing facility from April 11 to April 30,
2019.
Your complaint about being provided with erroneous or misleading information by the skilled nursing facility
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that a Freestyle Libre continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of glucose monitor. The records must show you are insulin dependent. Based on the medical records provided, you are not insulin dependent. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.