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 records provided support the need for IRF care.
The Plan denied your request. The Plan says the records do not show that the enrollee has changing conditions
that need a physician be seen several times a week with therapy three hours per day or an intensive team to
guide the care plan.
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 was medically stable with no evidence of a need for supervision by a
physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care.
Functionally, given her dementia with no carryover, the enrollee does not require IRF level of therapies. The
enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive
therapy program. An IRF admission is not medically necessary based on the enrollee's current functional status
and medical stability.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee has had functional decline
since her fall and is still able to follow instructions and participate in therapy. Daily therapy would help her
regain function. The Plan denied your request. The Plan says the enrollee is at her new functional baseline at
this stage in her fracture's healing process and would not benefit from daily therapy and has good pain control.
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 SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 91-year-old
female with a fall and left clavicle fracture. From a nursing perspective, the beneficiary received oral
medications. The beneficiary had stable vital signs. She was treated for pain with effect. She was treated for a
UTI. Regarding rehabilitation services, the beneficiary received PT and OT in the acute hospital. The
beneficiary was at a maximal assist level with functional mobility. The beneficiary required varying assist with
ADLs.
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs;
however, skilled therapy is not needed on a daily 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 SNF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an additional $80.18 for eyeglasses and contact
lenses provided on February 22, 2020.
You asked the Plan to reimburse you for the eyeglasses and contact lenses. You say that you are entitled to
$200 per year for eyewear however, the Plan applied the eyewear benefit to the least expensive item and the
Plan should reimburse you the difference of $80.18. The Plan denied your request. The Plan says the claim
processed correctly.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services with $200 per 1 calendar year.
We looked at the file and the Plan's rules. The file shows that the Plan paid you the correct amount for the
eyewear based on the Plan's eyewear benefit. Therefore, we decided that the Plan does not have to reimburse
you for an additional $80.18 for eyeglasses and contact lenses provided on February 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation.
You asked the Plan to pre-approve ambulance transportation. You say that the enrollee is unable to sit in a
wheelchair for transportation. The Plan denied your request. The Plan says Medicare does not cover ambulance
trips to doctor's offices.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pre-approve ambulance transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received 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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services 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 services needed are for custodial care.
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.
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 records do not
show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to
improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the
enrollee's level of function and/or prevent deterioration. The enrollee was noted to reach maximal medical
improvement in regards to PT per a 7/20/20 physician document. The enrollee's condition does not require the
ongoing professional skills of a therapist. As the enrollee does not require skilled nursing or skilled therapy the
services do not meet the definition of home health aide services per Section 50.2 and are not medically
necessary to the treatment of the enrollee's illness or injury by the skilled professional staff.
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 home health physical therapy services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epifix.
You asked the Plan to pre-approve Epifix. 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 Epifix. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found you have a non-healing foot ulcer. However, Epifix is not considered standard of care for the
treatment of this condition. There is no documented superiority of Epifix to other available treatment options.
Therefore, you do 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 Epifix have not been met. Therefore, we decided that the Plan does not have to
pre-approve Epifix.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for BRCA1 and BRCA2.
You asked the Plan to pre-approve genetic testing. You say that you are appealing with records. The Plan
denied your request. The Plan says the denial of authorization for this testing is correct, because there is no
documentation that the enrollee has a personal history of any cancer and has no relative with known BRCA1 or
BRCA2.
The Plan follows Medicare rules. Medicare rules say that BRCA1 and BRCA2 genetic testing are only covered
by Medicare for the specific clinical indications listed above and on the previous page. This testing is not
covered by Medicare for screening purposes.
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 genetic testing. Our reviewer says that
the enrollee does not meet the Medicare criteria for the requested genetic tests. Our physician reviewer found
the enrollee is noted to have a family history of breast cancer. There is no evidence that the enrollee's relatives
have known BRCA gene abnormalities. There is no evidence that the enrollee herself has breast cancer, ovarian
cancer, or pancreatic cancer. Under these circumstances, such testing is considered screening and is not shown
to be 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 genetic testing have not been met. Therefore, we decided that the Plan does not
have to pre-approve genetic testing for BRCA1 and BRCA2.
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 requested facility has a Covid-19 recovery
program. You are unable to move to any other facility in the area and will benefit greatly from this. The Plan
denied your request. The Plan says your needs can be met in a less intensive setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your
care needs can be met 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 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: 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 enrollee's needs are greater than the
current level of care can provide. The enrollee requires an LTACH level of care. The Plan denied your request.
The Plan says the enrollee's needs are being met in the current setting. The LTACH will not provide additional
services.
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 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 alternate level of care for any ongoing LTC
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation to podiatry appointments.
You asked the Plan to pre-approve the routine transportation trips. You say that the requested transportation
services are necessary. The Plan denied your request. The Plan says there is no documentation submitted of a
life-threatening emergency and the enrollee can safely be transported by another means, other than ambulance.
The Plan says that there is no coverage for transportation outside of ambulances.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance.
The Plan follows the same rule.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Medicare rules for coverage of transportation trips have not been met. Therefore, we decided that the
Plan does not have to pre-approve routine transportation to podiatry appointments.
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 admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to
safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not have
complex wound care or other ongoing SNF level SN need. Her functional level does not require skilled therapy
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively
provide medically necessary and reasonable treatment in a SNF. She does 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, this
enrollee does 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 admission to a SNF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC).
You asked the Plan to pre-approve a PWC. You say that this is necessary for you. The Plan denied your
request. The Plan says that this is not covered by Medicare for use outside.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve a power wheelchair (PWC).
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 LTACH Admission is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee's needs can be met at the
current level of care.
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 here 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 an alternate 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses, polycarbonate lens, progressive lens, U-V lens,
anti-reflective coating and tint photochromatic lens provided on March 10, 2020.
You asked the Plan to pay for the eyeglasses, polycarbonate lens, progressive lens, U-V lens, anti-reflective
coating and tint photochromatic lens. The Plan denied your request. The Plan says enhancements including but
not limited to the following are not covered through the allowance but may be purchased by the member at an
additional cost.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the eyeglasses provided are enhancements, which
are not a covered vision benefit with your Plan. Therefore, we decided that the Plan does not have to pay for
eyeglasses, polycarbonate lens, progressive lens, U-V lens, anti-reflective coating and tint photochromatic lens
provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
You asked the Plan to pre-approve the orthosis. You say that given that traditional rehab strategies have been
tried and failed, the enrollee has been referred by her physician for myoelectric orthotic restoration. The Plan
denied your request. The Plan says the clinical information did not support the medical necessity for this
service.
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 orthosis. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the MyoPro myoelectric is not the most appropriate available supply or level of service for the
enrollee in question considering potential benefits to the enrollee. It is not known to be effective, based on
scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is
not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the
MyoPro Orthosis will improve the long term outcomes for this enrollee, improve her hemiparetic arm function,
or be safe for long term use. There is insufficient evidence in the literature that this device will increase her
participation in bimanual activities. The MyoPro device is not medically necessary per the Social Security Act,
Section 1862 (a)1(A) and the 42 CFR 411.15(k).
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pre-approve the MyoPro myoelectric orthosis (L8702).