Persius/hicric huggingface dataset:
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 needs IRF care. The Plan denied your 
request. The Plan says the enrollee can safely receive the necessary services in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for shortness of breath and hypoxemia after recent COVID 19 infection. Medical conditions are 
stable. There are no medical needs requiring inpatient admission. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. 
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Desvenlafaxine ER for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under 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 Desvenlafaxine ER for the 
enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing (81162). 
 
You asked the Plan to pre-approve BRCA1 and BRCA2 genetic testing. You say that this is necessary for your 
care. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1 and BRCA2 genetic testing is covered 
only for the indications listed above. 
 
We looked at the file and Medicare rules. The record shows that you were recently diagnoses with breast 
cancer and do not have a family history of breast, ovarian, pancreatic or prostate cancer. The record also does 
not show that you are of Ashkenazi Jewish descent. Based on this information, we decided that Medicare rules 
for coverage of BRCA1 and BRCA2 genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve BRCA1 and BRCA2 genetic testing (81162).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental consultation (D9310) and the unspecified 
preventive service (D1999) provided on October 1, 2020. 
 
You asked the Plan to pay for the dental services. You say that had a consultation for a root canal. You say that 
you decided not to have the root canal done that day as the provider was out of network. You also say that you 
received a bill for $175 for the visit and do not know why. The Plan denied your request. The Plan says dental 
consultation is not listed as a covered service. The Plan says that the unspecified preventive service is not listed 
as a covered service. The Plan also says that 
 
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 items or services are not 
among those covered under this benefit. The Customer Handbook clearly states that if a dental item or service 
is not listed in the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan 
does not have to pay for the dental consultation (D9310) and the unspecified preventive service (D1999) 
provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insulin pump. 
 
You asked the Plan to pre-approve an insulin pump. You say that when the enrollee's current pump 
malfunctions, he should not have to go 1-2 weeks without the device for fear of severe consequences. The Plan 
denied your request. The Plan says there are no mechanical problems with the enrollee's pump. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has an insulin pump. The requested pump serves the same purpose as the 
enrollees current insulin pump. Therefore, we decided that the Plan does not have to pre-approve an insulin 
pump.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Interspinous Spacer System. 
 
You asked the Plan to pre-approve Vertiflex Interspinous Spacer System. 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 Vertiflex Interspinous Spacer System. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has chronic lower back pain with radicular pain. The 
documentation does not support spinal instability. The requested device is experimental. More research is 
needed to show safety and efficacy. 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 Vertiflex Interspinous Spacer System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Vertiflex Interspinous Spacer System.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home blood glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says that your HgA1c shows that you are not diabetic. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. The plan based their denial on your 
HgA1c level. The plan has not provided any medical records that show this level. Therefore, we decided that 
the Plan has to pre-approve a home blood glucose monitor.  
 
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: 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 all services that would be provided in the LTACH are being 
provided already in the current acute care setting already approved. 
 
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 patient 
is currently undergoing treatment at an acute care hospital (ACH) for CoViD-19. The enrollee was 
intubated/ventilated and subsequently received a tracheotomy. The enrollee is tolerating ventilator weaning. 
There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs 
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. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the addition of a tooth to an existing 
bridge (D5650) provided on April 20, 2020. 
 
You asked the Plan to pay the in network rate for the addition of a tooth to an existing bridge. You say that you 
were not able to find an in network dentist that was open and accepting new patients due to Covid-19. You say 
that you had a toothpick break off between your bridge and tooth. You say that this became infected by the 
time you found a dentist that would see you. You also say that you were advised to return in 2 weeks to have 
the tooth extracted and bridge adjusted. The Plan denied your request. The Plan says the addition of a tooth to 
an existing bridge is not listed as a covered service. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in 
network rate for the addition of a tooth to an existing bridge (D5650) provided on April 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on September 6, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you shouldn't have been 
discharged from the hospital to begin with. 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 $250 
copayment for ambulance services (PA).  
 
You have been asked to pay a $250 copayment for an ambulance trip. An ambulance trip falls within the 
ambulance services (PA) 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 an 
ambulance trip provided by a participating provider on September 6, 2020.  
 
We note your complaint about feeling like you shouldn?t have been discharged in the first place. Your 
complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a one-month hotel room stay. 
 
You asked the Plan to pre-approve the stay. You say that you need a suitable living accommodation for safe 
healing and recovery. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The plan rules state that lodging costs are only paid for by the plan for out-of-area 
transplant services. 
 
The requested lodging is for a foot surgery. This not coverable.Based on this information, we decided that 
Medicare rules for coverage of the stay have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a one-month hotel room stay.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that Entyvio is medically necessary for the enrollee. The 
Plan denied your request. The Plan says step therapy requirements have not been 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 Entyvio. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found the enrollee has not tried and failed or found 
the plan's required first step therapies to be ineffective.  The records provided do not indicate a sufficient 
medical rational why the plan's first line drugs would not be appropriate for the enrollee.  Therefore, 
authorization of Entyvio is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient consultation services provided to the enrollee on 
March 13, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the time limit for filing has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until 10/15/20. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for inpatient consultation services provided to the enrollee on March 13, 2019.
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 a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of a LTACH admission. 
 
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 is currently undergoing treatment at an acute care hospital (ACH) 
following genitourinary surgery. The enrollee was intubated/ventilated and subsequently received a 
tracheotomy. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs 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 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 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 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 SNF services. You say that the enrollee cannot tolerate 3 hours of physical 
and occupational therapy. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
care in the inpatient rehab facility. 
 
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 physician reviewer 
found that the enrollee is wheelchair-bound. She is at maximum to total assist for transfers and most activities 
of daily living. She is tolerating therapies, but is reported to be making slow progress in the acute inpatient 
rehabilitation facility. There are no acutely unstable medical conditions are reported. She does require skilled 
nursing or therapy services, but is receiving these in the acute inpatient rehabilitation facility. Transfer to a 
skilled nursing facility does not appear to be medically necessary. The enrollee does not require the services on 
an inpatient basis, only 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for knee surgery. 
 
You asked the Plan to pre-approve inpatient services. You say that the enrollee requires an inpatient level of 
care due to her comorbid conditions. The Plan denied your request. The Plan says the services can be safely 
provided in an outpatient setting. 
 
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 pre-approve inpatient services. Our physician 
reviewer found that the documentation pre-operatively does not indicates medical necessity for inpatient level 
of care services for the elective procedure. The records do not show that the enrollee has a condition that 
requires an inpatient admission for the approved surgery. The record does not show that the enrollee's 
necessary hospital care will span two midnights. Therefore, the requested inpatient services are not medically 
reasonable or 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 inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient hospital services for knee surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CPM device. 
 
You asked the Plan to pre-approve the CPM device. You say that you would like reconsideration because this 
device is medically necessary to aid in the healing of your knee after multiple surgeries. The Plan denied your 
request. The Plan says you do not meet medical necessity criteria for this device. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only if use of the device 
began within two days of receiving total knee replacement surgery.  
 
Records show that total knee replacement surgery was received on October 6, 2020. Use of a CPM device has 
not yet begun. This means that use of a CPM device was not started until more than two days had elapsed 
following total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve the 
CPM device.