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. The Plan denied your request. The Plan says LTACH 
admission is not medically necessary. 
 
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 that the enrollee appears to require additional acute care services, however, as she is 
still requiring a chest tube, which is leaking, she is not clinically stable enough for transfer at this time. The 
enrollee does not require services at the LTACH that are not already available at the current facility. There are 
not services available at the LTACH that the enrollee requires that are not available and covered at the current 
facility. Therefore, this request for LTACH services doesn't appear to be warranted based on the documentation 
provided and will be considered not medically 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 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 continued admission to a skilled nursing facility (SNF) 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is denied with a last covered day of August 9, 2020. 
 
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 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 beyond the last covered 
date. She does not have complex wound care or other ongoing SN need beyond the last covered date. 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 
beyond the last covered date. She 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, this 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve PET/CT scan of the whole body for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical information provided shows that the requested study would exceed the 
allowed limit. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found although this scan would 
exceed the allowed limit for PET scans, as the enrollee has had Merkel cell carcinoma since 2013, and the last 
PET/CT was abnormal. The recent CT of the neck raised the possibility of recurrence. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
PET/CT scan of the whole body for the enrollee.  
 
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 pre-approve FlowerAmnio injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested treatment is considered experimental, investigational, and unproven for the 
treatment of plantar fasciitis. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this particular case, amniotic tissue injections to painful plantar fascia is not considered standard of 
care. There are certainly anecdotal studies which demonstrate some effectiveness, however the studies are 
small with little long follow-up for this particular diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve FlowerAmnio injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.
You asked the Plan to pre-approve the requested wheelchair. You say that it is impossible to feel comfortable in the provided wheelchair. The Plan denied your request. The Plan says equipment used in a nursing home cannot be covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the requested wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for Durolane injections. 
 
You asked the Plan to reduce the cost share for the requested services. The Plan denied your request. The Plan 
says Part B products are not eligible for cost sharing reduction. 
 
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 enrollee's contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare Part B prescription drugs.  
 
The enrollee has been asked to pay a 20% coinsurance for the requested injection. The service falls within the 
Medicare Part B prescription drugs benefit category. This means that 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 reduce the cost 
share for Durolane injections.
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 is not currently getting the rehab she 
needs in order to return to baseline. The Plan denied your request. The Plan says the clinical information does 
not show that the guidelines for coverage of IRF care have been met. The Plan says that the clinical 
information shows that the enrollee's needs can safely be met in the current skilled nursing facility (SNF) or at 
a SNF without COVID-19 restrictions, if ordered by the doctor. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need transportation to avoid a 
lapse in case. The Plan denied your request. The Plan says your benefit only allows 48 trips for this service. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
The documentation shows that at the time of requests, 43 trips had been used. We looked at your request, the 
records in the case file, and the rules. Once 48 trips have been used, you will 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) 
provided to the enrollee on March 2, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on March 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog Flexpen. 
 
You asked the Plan to pre-approve Novolog Flexpen. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Novolog Flexpen.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visits for personal care. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is blind and bed ridden. 
The Plan denied your request. The Plan says custodial care is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that custodial care is not covered. 
 
We looked at the file, and Medicare rules. Based on the information provided, we decided that Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve home visits 
for personal care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the echocardiogram provided on February 
11, 2020. 
 
You asked the Plan to waive the deductible for the echocardiogram. You say that you were misinformed and 
did not know that you had a deductible for your medical expenses. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible that applies towards the echocardiogram.  
 
The echocardiogram you asked the Plan to waive the deductible for falls within the ?Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies? benefit category. The record shows you were mailed the Annual 
Notice of Change on August 2, 2019. 
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that 
applies towards echocardiogram. This cost sharing is a contractual obligation that had not been met at the time 
the echocardiogram was received on February 11, 2020. Therefore, we decided that the Plan does not have to 
waive the deductible for the echocardiogram provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown for tooth #10 (D2750) and core buildup (D2950).
You asked the Plan to pre-approve dental crown and core buildup. You say that these services are needed to prevent the removal of your teeth. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because you received a crown on tooth #10 on August 15, 2019 which is less than 60 months ago and core buildup with dental code D2950 is not covered by the Plan.
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. The Plan covers dental crowns once per tooth per 60 months. You received a crown on tooth #10 on August 15, 2019, therefore this benefit is currently exhausted. The requested core buildup is not covered by the Plan's dental benefits. Therefore, we decided that the Plan does not have to pre-approve a dental crown for tooth #10 (D2750) and core buildup (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan has to pre-approve FlowerAmnio injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the requested treatment is considered experimental, investigational, and 
unproven for the treatment of plantar fasciitis. 
 
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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this particular case, amniotic tissue injections to painful plantar fascia is not considered 
standard of care. There are certainly anecdotal studies which demonstrate some effectiveness, however the 
studies are small with little long follow-up for this particular diagnosis. 
 
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 not been met. Therefore, we decided that the Plan has to pre-
approve FlowerAmnio injections for the enrollee.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ENTRESTO tablets. 
 
You asked the Plan to pre-approve self-administered drugs. You say that other therapies have not been 
effective for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this drug 
is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's 
Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ENTRESTO tablets.
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 you are now stable. You required stand-by assistance/minimal assistance with 
transfers and walking. The documentation does not support that you require an intensive rehabilitation therapy 
program. Ongoing pain medication and other medication management, skin and O2 care, and daily therapy can 
be provided at a lower level of care. Therefore, you do not meet criteria for the requested IRF admission. 
 
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 continued skilled nursing facility (SNF) care from August 9, 2020.
You asked the Plan to pre-approve continued SNF care. The Plan denied your request. The Plan says continued SNF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that 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. The 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care from August 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication of a need for 24 hour nursing care or daily physician visits.

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 you are medically stable, with no evidence of need for supervision by a PMR physician or a need for acute rehab nursing care. Functionally, given your current level, you do not need the IRF level of therapy. You may benefit from PT and OT, but you do not require an intensive therapy program. This is admission is not medically necessary, based on your current functional status, and a lack of medical complexity.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).