Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 12 chiropractic visits. 
 
You asked the Plan to pre-approve 12 chiropractic visits. You say that you need these services. The Plan denied 
your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation when there is an expectation of improvement in 
function.  However, the Plan offers a chiropractic benefit that exceeds Medicare coverage. For that reason, the 
Plan?s coverage rules apply in this case. The Plan covers chiropractic services designed to help relieve pain, 
inflammation, swelling, or leg and foot numbness when one or more of the bones of the spine move out of 
position. 
 
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 12 chiropractic visits. Our reviewer 
says that the requested services meet criteria for coverage under the Plan's supplemental benefit. Our physician 
reviewer found the documentation supports that chiropractic manipulative therapy is medically reasonable and 
necessary to relieve neck and back 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 12 chiropractic visits have been met. Therefore, we decided that the Plan has to 
pre-approve 12 chiropractic visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 14, 2020 to 
February 18, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that 
the inpatient admission did not meet medical necessity criteria based on the 2019 Interqual criteria, Infection: 
Pyelonephritis acute level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee was admitted on February 15, 2020 for management of multidrug resistance 
klebsiella urinary tract infection/pyelonephritis. She had failed previous oral therapy. The record shows, that at 
the time of the inpatient admission, the admitting physician reasonably expected that the enrollee's necessary 
hospital care including earlier ED and/or observation care would span two midnights. The inpatient admission 
was 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 14, 2020 to February 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. You say that you need additional professional treatment before going on your own. The Plan denied your request. The Plan says you appear to be at your highest level of function attainable.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional services. Our physician reviewer found that the requested therapy is not generally accepted as specific and effective therapy for your condition. You have had 10 prior therapy sessions. The records do not indicate you require the ongoing unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to be performed only by a therapist, or under the supervision of a therapist. You have had training in a home exercise program. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design, or deliver a program to maintain your current condition, or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kidney transplant surgery. 
 
You asked the Plan to pre-approve kidney transplant surgery. You say that the enrollee has a transplant 
scheduled. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because there is documentation of prior non-compliance and current non-compliance with treatment which is a 
contraindication for transplant. 
 
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 kidney transplant surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while there is no documentation of active malignancy, severe cardiovascular disease, 
or severe pulmonary hypertension, there are potential concerns. There is documentation of active alcohol use 
and previous driving under the influence (DUI). The enrollee's support system has not been demonstrated to be 
adequate. There is documented non-adherence with the enrollee's medical regimen, both medication and 
hemodialysis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kidney transplant surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve kidney transplant surgery.
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 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 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 review indicates that the enrollee still requires acute hospital level of care 
services and is receiving appropriate care at the present acute care hospital. There is no documentation 
provided requiring admission to a LTACH. The review has determined that the enrollee does not require 
services at the LTACH that are not available at the acute care hospital where they are currently receiving care. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical needs can now be safely met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not require ongoing 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. You do not have 
complex wound care or other ongoing SNF level SN need. You have been self-limiting in therapy and does not 
require ongoing 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. You do not require skilled nursing or skilled therapy services (or a combination of these 
services) on a "daily basis" in a SNF beyond the last covered date. As a practical matter, you do 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do 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. You do 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. You do not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve a power wheelchair. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the enrollee is able to ambulate in the home with a walker. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the enrollee's condition can be improved by a walker, cane or manual wheelchair. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair for the enrollee.
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 would benefit from going to 
a LTACH. You also say that going into a LTACH would be very beneficial in the enrollee's condition, where 
her needs are the priority and potential recovery can be met faster. The Plan denied your request. The Plan says 
this service 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 the documentation does not support that the enrollee requires services at the LTACH 
that are not available at the acute care hospital where she is currently receiving care. Our reviewer also found 
that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thoracoscopy with therapeutic wedge resection 
(32666) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve a thoracoscopy with therapeutic wedge resection to be provided by an OON 
provider. You say that you would like the procedure to be billed at an in-network level of benefit. 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 
a thoracoscopy with therapeutic wedge resection (32666) to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 36 one-way transportation 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 (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis. 
 
You asked the Plan to pre-approve knee orthosis. You say that the enrollee has instability and you are 
appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this 
item is correct, because the enrollee does not have recent surgery, injury, or objective evidence of instability. 
 
The Plan follows Medicare rules. Medicare rules say that knee instability must be documented for coverage of 
a knee orthosis. 
 
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 knee orthosis. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested knee orthosis. Our physician reviewer found 
the documentation reveals that the enrollee is ambulatory but does not reveal objective evidence upon physical 
examination of knee instability. There is no evidence of a recent injury or surgery to the knees. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after 
August 19, 2020. 
 
You asked the Plan to pre-approve SNF care. You say that you need more therapy. The Plan denied your 
request. The Plan says the denial of authorization for continued SNF care is correct. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled 
Nursing Facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued Skilled Nursing Facility (SNF) care after August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the out of network office visit. You say that you are going to have to do 
another operation after chemotherapy. You say that delaying this surgery could cause the cancer to spread. You 
say that you need to have this procedure done in order to have a few more years to live. You say that you are 
not a young woman and that delaying this process could result in your death. You say that making another 
appointment might take a week or longer. You say that due to the virus and pandemic you going from doctor to 
doctor is not fair to you. The Plan denied your request. The Plan says the requested provider does not 
participate in the Plan's network. The Plan says that there are in network providers who are available and able 
to treat your condition. 
 
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 
an office visit to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the skilled therapies that she is currently receiving will be ending. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.