Persius/hicric huggingface dataset:
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 indicates that the enrollee is receiving appropriate care at the 
current acute care facility. She does not appear safe for discharge as she is developing metabolic acidosis, is in 
wrist restraints, and pulling on her trach and peg. There is no documentation provided requiring admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The review indicates that 
the enrollee does not require services at the LTACH that are not available at the acute care hospital where she 
is 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gynecology/oncology services to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON gynecological oncology services. You say that you feel that since 
the enrollee had a complication from the prior surgery, you do not trust these network providers to provide her 
care. The Plan denied your request. The Plan says the requested OON referral is not approved as there is a 
qualified provider able to meet the enrollee's needs. Although there was an issue with another provider at the 
facility, there is no evidence that the approved physician would be unable to provide treatment for the enrollee's 
disease. 
 
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 
the gynecology/oncology services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology genomic profiling 
provided to the enrollee on May 5, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic 
profiling for stomach cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Guardant360 molecular pathology genomic profiling provided to the enrollee on May 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute 
care facility. 
 
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 
is receiving appropriate care at the present acute care hospital. 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. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyzulta Sol 0.024% for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the benefit covers those drugs covered under traditional Medicare Part A and Part B. 
 
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 Vyzulta Sol 0.024% for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued admission to an inpatient mental health 
facility. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is 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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not 
meet the criteria for treatment in an acute inpatient mental health treatment facility beyond the date in question. 
You could be treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, 
auditory or visual hallucinations, and not showing any behaviors, being compliant with treatment while 
awaiting placement. 
 
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 continued admission to an inpatient mental health facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip arthroplasty and an inpatient admission 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 because the requested service is not medically necessary, the related inpatient hospital 
admission is also 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no specific clinical rationale for an inpatient admission for the proposed elective procedure. The 
review has determined that the requested inpatient admission is not medically necessary or reasonable. 
 
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 hip arthroplasty and an inpatient admission 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 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 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 was admitted to an acute care hospital with acute respiratory failure 
related to COVID-19. The enrollee required intubation and mechanical ventilation support and was treated with 
oxygen, remdesivir, and convalescent plasma. The course was complicated by cardiac arrest leading to anoxic 
brain damage and encephalopathy. EEG showed diffuse slowing. The enrollee does not require any services at 
the LTACH that are not available and appropriate at a lower level of care. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at a lower level of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve the requested test strips. The Plan denied your request. The Plan says the 
requested diabetic supplies are not a preferred brand covered under your plan. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufactures as 
preferred. 
 
We looked at the file and Medicare rules. The documentation does not indicate that you are unable to use a 
plan-preferred brand. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay was medically necessary. The Plan denied 
your request. The Plan says the stay 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoe lifts. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered for the enrollee's condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve shoe lifts.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs the LTACH level of 
care. The Plan denied your request. The Plan says rules for LTACH care have 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 that there is no evidence that the enrollee requires services that are not currently 
available. As LTACHs and acute care hospitals (ACH) are licensed to provide the same level of care, there is 
no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH 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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ENTYVIO. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was diagnosed with 
inflammatory bowel disease (IBD) by colonoscopy on May 4, 2020.  
 
Remicade was started in June of 2020 and the enrollee has shown partial response. No results of therapeutic 
drug monitoring nor of fecal calprotectin were provided. Also, available records do not support that Remicade 
has not been dose-optimized. She has not tried and failed the Plan's require drug, STELARA, and the records 
do not support that the required drug would be less effective or contraindicated. ENTYVIO is therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ENTYVIO.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and a mandibular partial 
denture. 
 
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that 
you are dissatisfied with how your current dentures fit. The Plan denied your request. The Plan says these 
services are allowed once every 60 months. The Plan also says that you had these services less than 60 months 
ago. 
 
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, dentures are limited to one set every 5 
years. The record shows that you received a complete maxillary denture and a mandibular partial denture on 
July 8, 2018 and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have 
to pre-approve a complete maxillary denture and a mandibular partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lupectomy to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve a lupectomy. You say that you would like approval for this surgery. The 
Plan denied your request. The Plan says these services 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 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 lupectomy 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the needs can be met 
at a different level of 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 that 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. Our reviewer 
says that the enrollee may benefit from multiple therapies, but the documentation does not support that their 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve detachable armrests with adjustable height (E0973). 
 
You asked the Plan to pre-approve detachable armrests with adjustable height. You say that you need this item. 
The Plan denied your request. The Plan says the records do not show this is necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an adjustable arm height option is covered if the 
beneficiary requires an arm height that is different from that available using nonadjustable arms and the 
beneficiary spends at least 2 hours per day in the wheelchair. 
 
We looked at the file and Medicare rules. The records do not document that you need an arm height that is 
different from that available using nonadjustable arms. Based on this information, we decided that Medicare 
rules for coverage of detachable armrests with adjustable height have not been met. Therefore, we decided that 
the Plan does not have to pre-approve detachable armrests with adjustable height (E0973).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair for the enrollee. 
 
You asked the Plan to pre-approve a shower chair. You say that the enrollee is a fall risk in the shower without 
a shower chair. The Plan denied your request. The Plan says that this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair for the enrollee.