Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexium. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not a covered benefit. 
 
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 Nexium.  
 
Benefits for these services 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. The Plan denied your request. The Plan says 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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital with COVID-19 positive test, 
shortness of breath, and chest pains. He had ventricular fibrillation, which was successfully converted to sinus 
rhythm. He was intubated when trial of CPAP and AVAPS failed. He has since been extubated, however 
breathing is still difficult on high flow oxygen and breathing treatments. Eating is still challenging due to 
breathing status. The enrollee appears to be improving, however, ongoing acute care is needed at this time until 
stable. However, it is unlikely that the enrollee will require acute care services for more than an additional 24 
days. The enrollee does not require services at the proposed LTACH that are not available at the current 
facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 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. 
Records do not indicate that there are significant, or complex medical/nursing issues that could not be 
addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, 
and daily therapy can be provided at a lower level of care. In this case, the member is mostly MODERATE to 
MAX assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy 
may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF 
level of care. 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110 and 97112) provided on 
December 30, 2019. 
 
You asked the Plan to pay for the therapeutic exercises. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the submitted medical records do not 
support the total time required for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
The CPT Code Manual definition of code 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; 
neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities. 
 
We asked our coder 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 therapeutic exercises. Our reviewer says that CPT codes 
97110 and 97112 do not meet criteria for billing or reimbursement consideration. Our reviewer found the 
documentation does not indicate the time spent performing these services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapeutic exercises have not been met. Therefore, we decided that the Plan 
does not have to pay for therapeutic exercises (97110 and 97112) provided on December 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B injections provided from May 
15, 2019 to October 22, 2019. 
 
You asked the Plan to waive the coinsurance for the Part B injections. You say that if you had known there was 
a cost share, you would have refused the injections. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 20% 
coinsurance for chemotherapy and other drugs covered by Medicare Part B.  
 
You have been asked to pay a total of $1,774.80 for the Part B injections. The Part B injections fall within the 
Medicare Part B prescription drugs benefit category. See chart below. 
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
May 15, 2019 Part B injection $2,221.20 20% $444.24 
July 2, 2019 Part B injection $2,223 20% $444.60 
August 28, 2019 Part B injection $2,223 20% $444.60 
October 22, 2019 Part B injection $2,206.80 20% $441.36 
Total    $1,774.80 
 
  
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 coinsurance for the Part B injections provided from May 15, 2019 to 
October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from February 12, 
2020 through February 17, 2020 provided by an in-network provider. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told the provider 
could not do the procedure until Monday so you had to stay longer. The Plan denied your request. The Plan 
says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on February 12, 2020 and discharged on February 17, 2020. 
You were asked to pay a $295 copayment per day from February 12, 2020 through February 16, 2020, days 1-5 
of your inpatient hospital care. You were discharged on February 17, 2020 and there was no copayment charge 
for the day of discharge. Per your contract there is a $295 copayment per day required for days 1-5 for in-
network inpatient hospital care. 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 inpatient hospital care from 
February 12, 2020 through February 17, 2020 provided by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee was previously independent with basic 
activities of daily living and functional mobility. The Plan denied your request. The Plan says the enrollee does 
not require a high level of physician supervision in combination with therapy services. 
 
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 physician reviewer found 
that the enrollee presented to the acute hospital with left hip pain after a fall. She underwent surgical repair of 
the fracture. She is not able to fully stand. She is at maximum assist for transfers and is moderate to maximum 
assist for activities of daily living. She is otherwise medically stable. The complexity of the enrollees nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services, 
but does not require an intensive inpatient rehabilitation therapy program. 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. 
 
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 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 show the enrollee does not need 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 medical records show that the complexity of the enrollee's nursing, medical, and 
rehabilitation needs do not require an IRF stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does require physical therapy and occupational therapy services, but not as part of an intensive 
inpatient rehabilitation therapy program. 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 IRF. Care at the skilled nursing 
facility level appears to be more appropriate in this case. 
 
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 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 needs can be safely met at a lower 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 do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued 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 your needs appear to be custodial. 
 
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 continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography (95811). 
 
You asked the Plan to pre-approve polysomnography. You say that the enrollee needs this because her PAP 
therapy is not working. The Plan denied your request. The Plan says the records do not demonstrate the need 
for a new sleep study. 
 
The Plan follows Medicare rules. Medicare rules say that repeat PSG may be indicated when medically 
necessary in circumstances detailed 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 polysomnography. Our reviewer says 
that the requested study is not medically necessary. Our physician reviewer found this patient has severe 
obstructive sleep apnea (OSA).  A previous positive airway pressure (PAP) titration was successful.  The 
patient has had a CPAP device for more than a year but is not using it because of discomfort with the interface.  
A repeat PAP titration will not necessarily address the interface problems.  There is no mention of trials of 
alternative interfaces, ramp-up pressure, or other measures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve polysomnography (95811).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
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 any skilled needs can be provided on an intermittent basis utilizing part 
B benefits. 
 
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 the enrollee's 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee did not do well in a lower 
level of care. The Plan denied your request. The Plan says that the enrollee is not ready to transfer from the 
acute care setting. 
 
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 electrolyte abnormalities. The enrollee is 
not intubated/ventilated. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you require more therapy. The Plan denied your 
request. The Plan says that your needs can be safely met at a lower level. 
 
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 continued 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 continued skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
with cystitis and a stroke. She received oral medications and had stable vital signs. She was treated for a 
urinary tract infection. She received physical and occupational therapy in the hospital and needs assistance with 
walking to 70 feet with a rolling walker. She needs varied levels of assistance with activities of daily living. 
She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily 
basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.