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

 
We decided that the Plan does not have to pay for SNF services provided on November 5, 2019 through 
November 10, 2019. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration because you were 
told by the Plan that RUG codes would be honored until 2020. The Plan denied your request. The Plan says 
non-participating providers must bill their claims with valid PDPM code effective October 01, 2019. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. This claim was billed without an appropriate PDPM code. 
Therefore, we decided that the Plan does not have to pay for SNF services provided on November 5, 2019 
through November 10, 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 you are appealing. The Plan denied your request. 
The Plan says the denial of authorization for IRF service is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 does 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. While the 
enrollee may benefit from multiple therapies such as physical and occupational therapy, the documentation 
does not support that the enrollee's high 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided by a 
participating provider on February 21, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were told that you would 
not 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 $150 
copayment for ambulance services.  
 
You have been asked to pay a $150 copayment for ambulance services. The correct copayment has been 
applied to the services that were provided. Ambulance services fall within the ambulance 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 ambulance services provided by a participating 
provider on February 21, 2020.
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 admission. You say that SNF care would be of benefit for this 
enrollee. The Plan denied your request. The Plan says there are no daily skilled care needs in this case. 
 
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 admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found The patient 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. She does not have 
complex wound care or other ongoing skilled nursing SNF need. Her 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. She does not require skilled 
nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical 
matter,  this patient 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 SNF admission 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 continued inpatient psychiatric services after August 12, 
2020. 
 
You asked the Plan to pre-approve continued inpatient psychiatric services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 pre-approve continued inpatient psychiatric services. 
Our reviewer says that the documentation does not support that the requested continued inpatient psychiatric 
services are medically reasonable or necessary. Our physician reviewer found the enrollee was admitted to the 
acute inpatient psychiatric hospitalization on July 14, 2020 with Schizoaffective Disorder Bipolar Type. The 
documentation does not support that it was expected the enrollee would improve in a reasonable period of time 
beyond the dates in question as the enrollee was not showing any dangerousness to self or others, auditory or 
visual hallucinations being compliant with treatment. The enrollee is not required seclusion and restraint and 
was less belligerent. The documentation does not support that the enrollee required inpatient mental health 
treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not 
have any illusions, auditory or visual hallucinations. Therefore, the enrollee does not meet criteria for the 
requested 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 continued inpatient psychiatric services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric services after August 12, 
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 the enrollee would be best treated in the IRF setting 
as nursing facilities are full of COVID patients. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria for IRF 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. Our 
physician reviewer found the enrollee was admitted after a left total knee replacement due to acute kidney 
injury and urinary retention. 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 or can tolerate 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: 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 enrollee meets the Medicare criteria for LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH service 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 the enrollee does not require services at the LTACH that are not already available at the current facility. Additional acute care services appear to be needed; however, considering the improvements thus far it is not clear that the enrollee would require at least an additional 25 days of acute 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 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 skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the clinical documentation provided supports 
the need for SNF care. The Plan denied your request. The Plan says the guidelines for coverage of SNF care 
have not been met. The Plan says that the services needed can be safely received at a different setting.  
 
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 services. 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. She does not have 
complex wound care or other ongoing skilled nursing needs beyond the last covered date. His 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 beyond the 
last covered date. He does not require skilled nursing or skilled therapy services (or a combination of these 
services) on a "daily basis" beyond the last covered date. As a practical matter, the enrollee does not require the 
necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Maintenance Wakefulness Test (MWT) 
 
You asked the Plan to pre-approve MWT. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 MWT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare does not cover services required by a third party. Examples of non-covered services 
are physical examinations that are not medically necessary, such as those required by employment, insurance, 
licensing, marriage, and court-ordered examinations". The ordering physician's office has indicated that this 
test is needed for licensing, and not for a medical need. Therefore, you do not meet criteria for the requested 
testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MWT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Maintenance Wakefulness Test (MWT)
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 receiving appropriate in-patient acute 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 enrollee 
does not require any services at the proposed LTACH that are not already available at the current acute care 
facility. Based on the gradual improvement thus far, it is unlikely the enrollee would require more than 25 
additional days of acute care services, based on the documentation provided. 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for LTACH service 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 the enrollee does not require services at the proposed LTACH that are not already 
available at the current facility. Additional acute care services appear to not be needed for much longer, transfer 
to a lower level of care can be arranged soon. 
 
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 chiropractic services and Visco Gel injections to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services and Visco Gel injections. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested chiropractic 
services can be provided by a network provider. The plan also says that the requested injections are not a 
covered benefit when provided by a chiropractor. 
 
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 rules also say 
that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.  
 
The records show that the requested injection services at issue is not manual manipulation of the spine. In 
addition, 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 chiropractic services and Visco Gel injections to be provided by an out of network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IV sedation. 
 
You asked the Plan to pre-approve the IV sedation. You say that you are a very high anxiety dental patient and 
the only way to be successful in your dental care would be with sedation. You say that the procedure needs to 
be done in order to avoid losing teeth. The Plan denied your request. The Plan says the services being requested 
are non-covered. 
 
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 services are only covered 
under your benefits when provided in conjunction with covered endodontic, periodontic, or oral surgery dental 
care. There is also coverage for dental anesthesia or sedation when medically necessary for developmentally 
disabled persons. The records show that the dental services you are scheduled to receive are crowns and 
fillings. This restorative type of work is not considered endodontic, periodontic, or an oral surgery. There is no 
evidence that you are a developmentally disabled person. Therefore, we decided that the Plan does not have to 
pre-approve IV sedation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the criteria for a 
LTACH appropriate admission. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care. The Plan also says that the enrollee does not require transfer to a LTACH. 
 
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 advantage in transferring the enrollee to the LTACH. Our reviewer also found that the enrollee can 
remain at the current acute care hospital until such time no acute services are required. The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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 LTACH services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the right shoulder. 
 
You asked the Plan to pre-approve MRI. You say that you are appealing. The Plan denied your request. The 
Plan says that the denial of authorization for this service is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested MRI. Our physician reviewer found the enrollee has 
known metastatic disease and abnormality in the shoulder that needs better characterization due to pain. This 
study is indicated for better characterization of the cause of the enrollee's pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI have been met. Therefore, we decided that the Plan has to pre-approve 
Magnetic Resonance Imaging (MRI) of the right shoulder.