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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services this member requires can be rendered in a skilled nursing 
facility 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. 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 VP shunt for normal 
pressure hydrocephalus. She was then transferred to acute inpatient rehabilitation on 8/11/2020. Medical 
problems are now stable and there is no documentation of need for ongoing management by rehabilitation 
physician. 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 record supports a need for physical and occupational therapy, it does not support a 
need for continuation of an intensive rehabilitation therapy 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF 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 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from March 12, 2020 to 
March 13, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like to appeal the self-
administered drugs that were provided while you were in an outpatient setting at the hospital.  The Plan denied 
your request. The Plan says self-administered drugs are not covered in the outpatient setting under Medicare 
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 pay for the self-administered drugs 
provided from March 12, 2020 to March 13, 2020.  
 
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for your weight management class. 
 
You asked the Plan to reimburse for the services. The Plan denied your request. The Plan says you have not 
submitted all receipts. 
 
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 there is a $150 benefit 
limit for weight loss programs. To obtain this reimbursement please submit a Wellness Allowance 
reimbursement form along with proof of payment and any additional information outlined on the form. 
 
Review of the file shows that you had not submitted all of the necessary documentation for the full $150 
benefit reimbursement for the weight loss program. The Plan is not required to reimburse for the services until 
this documentation is submitted. Therefore, we decided that the Plan does not have to reimburse for your 
weight management class.
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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does require physical therapy and occupational therapy services but the 
enrollee does not appear to be stable to leave the acute hospital at this time. Based on the medical records 
provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility due to her ongoing hyperglycemia 
and hyperkalemia. Continued care in the acute hospital appears to be more appropriate until she is stable for 
transfer for rehabilitation. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options coded as K0861 with a power tilt/recline seating system coded as E1007 along with other 
components/accessories. 
 
You asked the Plan to pre-approve the Group 3 PWC with accessories. You say that this is medically necessary 
for this enrollee. The Plan denied your request. The Plan says because the criteria for the power tilt/recline 
system are not met, the PWC coded as K0861 cannot be approved. 
 
The Plan follows Medicare rules. Medicare rules say that a power wheelchair with multiple power options can 
only be covered if the enrollee meets the criteria for a power tilt/recline system or the beneficiary uses a 
ventilator which is mounted on the wheelchair. The power tilt/recline system is covered when the above 
referenced criteria are met.  
 
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 Group 3 PWC with accessories. Our 
reviewer says that the criteria for a PWC with multiple power options are not met in this case. Our physician 
reviewer found the patient does not self-catheterize. The documentation indicates no physical exam evidence of 
spasticity on treating practitioner physical examination portion of progress notes. The patient is able to weight 
shift laterally and forward independently. 
 
 
 
 
 
 
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 Group 3 PWC with accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options 
coded as K0861 with a power tilt/recline seating system coded as E1007 along with other 
components/accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 1, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no 
network deficiency for the services, and alternate network providers were found. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the lab services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided 
that the Plan does not have to pay for the lab services provided on November 1, 2019 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the record 
supports a need for physical and occupational therapy, it does not support a need for an intensive rehabilitation 
therapy program. There is not a reasonable expectation that this enrollee 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health services. 
 
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says the 
remaining visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
The documentation shows that 23 home health visits were requested. The Plan has agreed to pre-approve 12 
visits. 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 additional services. Our 
physician reviewer found that the enrollee is non-weight bearing. He is unable to complete his own wound care 
due to wound location. The records do not show that skilled nursing services are required to effectively provide 
treatment, in order to improve the enrollee's condition, or to establish a maintenance program to maintain his 
condition, or prevent deterioration. He does not have complex wound care or other skilled nursing. He has been 
educated in disease management and medications. Therefore, the requested 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 additional services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional home health services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided March 4, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you do not feel that you 
should be charged for this fee. You feel that you have plenty of cost shares from the hospital that you are 
willing to pay and not complain about but this is not one of them. The Plan denied your request. The Plan says 
you were charged this cost sharing correctly. 
 
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 $325 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $325 for these 
services. 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 the ambulance services provided March 4, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism and a seat lift chair 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 notes do not show severe arthritis or severe neuromuscular weakness. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
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 medically reasonable or necessary. Our physician reviewer found the documentation 
does not reveal objective imaging evidence that the enrollee has severe arthritis of the hip. The documentation 
does not reveal that the patient has a neuromuscular disease. Arthrogryposis is a physical finding of multiple 
contractures that can accompany numerous disorders and neurologic conditions but does not need to be caused 
by a neurologic insult. The documentation does not support that a seat lift is likely to effect improvement in the 
enrollee's condition or arrest or retard deterioration in the enrollee's condition. 
 
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 a seat lift mechanism and a seat lift chair for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on January 24, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted 
to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 4, 2020. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case and the referring provider are not network providers with the Plan. The Plan 
did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these 
services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided 
on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physician fee or the facility charge for 
services provided on April 3, 2020. 
 
You asked the Plan to waive the copayments for the physician and facility services. You say that you should 
not have any copayments. The Plan denied your request. The Plan says you were charged the copayments 
correctly. 
 
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 $50 
copayment for Outpatient Hospital Services and a $50 copayment for Outpatient Surgery including services 
provided at hospital outpatient facilities.  
 
You have been asked to pay a $50 copayment for the physician service and a $50 copayment for facility 
services. The physician and facility services fall within the Outpatient Hospital Services and Outpatient 
Surgery including services provided at hospital outpatient facilities benefit categories. 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. Supplies have no charge but services 
have a copayment. Therefore, we decided that the Plan does not have to waive the copayments for the 
physician fee and facility charge for services provided on April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says this is not an item that is covered by Medicare at this time. 
 
The Plan must follow Medicare rules. The DME MAC has determined that there is not sufficient evidence to 
support the medical necessity of a knee scooter at this time. Therefore, we decided that the Plan does not have 
to pre-approve a knee scooter.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you do not need more daily skilled therapy. 
 
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 your condition does not meet 
Medicare criteria for 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 skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental abutment services for tooth #3. 
 
You asked the Plan to pre-approve the dental services. You say that you are having trouble swallowing. The 
Plan denied your request. The Plan says the services are not covered with your 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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental 
abutment services for tooth #3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental core buildup, pontic, and retainer crown. 
 
You asked the Plan to pre-approve the dental services. You say that you have not been able to eat normally. 
The Plan denied your request. The Plan says the services are not a covered benefit. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental core 
buildup, pontic, and retainer crown.