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 enrollee's care can be safely provided 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care only in an IRF. The patient would benefit from a 
facility that could monitor and accommodate ventilator weaning however it does not appear that her care 
requires an IRF level program. The patient may benefit from multiple therapies such as physical and 
occupational therapy but the documentation does not support that the patient's functional status can tolerate or 
requires an 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on February 3, 
2020, and February 4, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says the 
inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the enrollee's vital signs were stable upon admission and remained 
stable throughout the one-midnight hospitalization. He was discharged home on with outpatient follow-up. The 
record did not show that at the time of inpatient admission the admitting physician reasonably expected that the 
enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided on February 3, 2020, and February 
4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for eyeglasses (V2200, V2784, V2799) provided June 30, 
2020. 
 
You asked the Plan to pay in full for the eyeglasses. You say that the eyewear should be covered. The Plan 
denied your request. The Plan says the total cost exceeds the allowance provided. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $250 annually for eyeglasses or contact lenses. 
 
We looked at the file and the Plan's rules. The total cost of the eyewear at issued was $429.95. This exceeds the 
plan allowance of $250. The plan is not responsible for any amount over the allowance provided. Therefore, we 
decided that the Plan does not have to pay in full for eyeglasses (V2200, V2784, V2799) provided June 30, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on June 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 
services are not covered. 
 
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 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 services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on June 
4, 2020.
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 enrollee can safely receive the services needed 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. 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 surgical repair of a 
right hip fracture. Medical problems are stable. 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. The medical record supports a need for physical and 
occupational therapy but it does not support a need for 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental crowns (CPT D2752) on tooth #8 and #9. 
 
You asked the Plan to pre-approve the crowns. You say that the crowns being requested are medically 
necessary. The Plan denied your request. The Plan says that the teeth do not appear to have significant 
breakdown due to decay or trauma. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crowns 
when the services are medically necessary and reasonable. 
 
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 crowns. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found a review of the enrollee's dental record and 
radiographs indicate that tooth #8 and #9 show significant coronal breakdown. Our physician reviewer found 
that crown restorations are reasonable and necessary to restore these teeth to adequate function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have been met. Therefore, we decided that the Plan has to pre-
approve dental crowns (CPT D2752) on tooth #8 and #9.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroxyzine tablets. 
 
You asked the Plan to pre-approve the Hydroxyzine tablets. You say that the drug being requested is medically 
necessary. The Plan denied your request. The Plan says the drug being requested is not covered under Part B. 
The Plan says that the enrollee does not have Part D drug coverage through their company. 
 
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 Hydroxyzine tablets.  
 
Benefits for the Hydroxyzine tablets 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis Eye Emulsion. 
 
You asked the Plan to pre-approve the eye drops. You say that you would like reconsideration because this 
drug is medically necessary. The Plan denied your request. The Plan says this medication is not covered for 
your condition 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 pre-approve Restasis Eye Emulsion.  
 
Benefits for the eye drops 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent 300 mg/2ml. 
 
You asked the Plan to pre-approve the Dupixent. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this drug is not covered for the member's 
condition by 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 pre-approve Dupixent 300 mg/2ml.  
 
Benefits for the Dupixent 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent 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 Dupixent 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: 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 care is medically necessary. The 
Plan denied your request. The Plan says transfer to an LTACH is not medically necessary. 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. Our 
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
osteomyelitis of the foot.  The enrollee is receiving wound care and a prolonged course of antibiotics.  The 
enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires services that are not 
currently available. There is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain 
at the current ACH until such a time that 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 long term acute care hospital (LTACH) services.
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 you need acute therapy to prevent further health 
issues. You say that your mobile skills are non-existent and that you rely on assistance to perform daily tasks. 
The Plan denied your request. The Plan says the records do not show that the enrollee needs to be seen by a 
rehab doctor three times per week, nor is there a need for an intensive team for care. The Plan says that the 
enrollee can safely receive the services needed in another 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for abdominal surgery. The enrollee's medical problems are stable. There are no complex nursing 
or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports 
a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation 
therapy program. There is not a reasonable expectation that the 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer for the 
enrollee. 
 
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 spacer. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device is experimental. More research is needed to show safety and efficacy. 
 
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 spacer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Vertiflex Superion interspinous spacer for the enrollee.
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 the SNF services. You say that the records provided support the need for 
SNF care. You say that the enrollee needs inpatient rehabilitation in order to regain normal function and so that 
she can be monitored for her various medical conditions. The Plan denied your request. The Plan says the 
guidelines for coverage of SNF care have not been met. The Plan says that the enrollee does not need skilled 
nursing services or daily skilled services that can only be provided on an inpatient basis in a SNF. 
 
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 services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and was treated for CHF. The enrollee received physical therapy and 
occupational therapy in the acute hospital. The enrollee was at an independent to supervision level with 
functional mobility, including gait to 40 feet with a front-wheeled walker. The enrollee required varying assist 
with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity 
of illness or the 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 the 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 continued inpatient psychiatric hospital services 
beginning October 1, 2020. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that the records received show your 
condition has improved and you are no longer a threat to yourself or others. 
 
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 inpatient psychiatric hospital services. 
Our reviewer says that continued inpatient psychiatric hospital services are not medically reasonable and 
necessary in this case. Based upon review the records provided it is not expected you would improve in a 
reasonable period of time for the dates in question as you did have vague suicidal ideation with the plan 
although it is unclear, no homicidal ideation noted and you had auditory or visual hallucinations with response 
to internal stimuli which did not appear new. You were compliant with treatment while not showing any acute 
threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care beyond the dates in question as you did have 
suicidal thoughts with the plan although they were vague, no homicidal thoughts and were compliant with your 
treatment. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient 
psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric hospital services beginning October 
1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (receiver) for the enrollee. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that  The Plan denied your request. 
The Plan says that replacement is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no 
case can be less than five years. The enrollee received a continuous glucose monitor on June 18, 2019, which is 
less than five years ago. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor (receiver) for the enrollee.