Persius/hicric huggingface dataset:
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 requires daily physician management, 
nursing, and intensive therapies. The Plan denied your request. The Plan says the enrollee's care is not complex, 
and does not need a team of providers. 
 
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 is at a contact guard assist level for sitting up, standing up, toilet and shower transfers, and 
walking using a four-wheeled walker. 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. 
 
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-approveenteral nutrition home therapy (S9342).You asked the Plan to pre-approvethe enteral nutrition home therapy. You say that you would like reconsideration because this is your main food source.The Plan denied your request. The Plan says the requested liquid nutritional supplement is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the enteral nutrition home therapy have not been met. Specifically, this service is not a Medicare covered benefit.Therefore, we decided that the Plan does not have to pre-approveenteral nutrition home therapy (S9342).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consult and treatment services to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve consult and treatment services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by 
a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
consult and treatment services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the  BiPAP with backup rate (E0471). 
 
You asked the Plan to pre-approve the BiPAP. You say that you would like reconsideration because this 
equipment is medically necessary. The Plan denied your request. The Plan says that this supply is not allowed 
for a patient with a primary diagnosis of OSA. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 BiPAP. Our reviewer says that this 
patient meets criteria for a primary diagnosis of complex sleep apnea. Our physician reviewer found OSA was 
diagnosed during the diagnostic portion of the sleep study. CPAP was unsuccessful in eliminated the sleep-
disordered breathing. BiPAP led to the emergence of central events, establishing the diagnosis of complex 
sleep apnea. The PAP titration study demonstrated that simple BiPAP failed to adequately treat the patient, and 
that E0471 is medically 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 the BiPAP have been met. Therefore, we decided that the Plan has to pre-
approve the  BiPAP with backup rate (E0471).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq, Avastin, and Fosaprepitant (J9022, J9035, 
J1453). 
 
You asked the Plan to pre-approve Tecentriq, Avastin, and Fosaprepitant. You say that these drugs are 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says these drugs are 
not FDA (Food and Drug Administration) approved for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tecentriq, Avastin, and Fosaprepitant. 
Our reviewer says that these chemotherapy drugs are not FDA approved for the enrollee's condition. Our 
physician reviewer found this patient has received prior immunotherapy. Accordingly, Tecentriq, Avastin, and 
Fosaprepitant are not FDA approved as treatment of unresectable or metastatic hepatocellular carcinoma (in 
combination with bevacizumab) in patients who have not received prior systemic therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq, Avastin, and Fosaprepitant have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Tecentriq, Avastin, and Fosaprepitant (J9022, J9035, J1453).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 days of skilled nursing home health services. 
 
You asked the Plan to pre-approve home health services. You say that home health skilled nursing services are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not require home health 
skilled nursing services. 
 
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 home health services. Our reviewer 
says that home health services are not medically necessary. Our physician reviewer found the enrollee does not 
have documented skilled nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 30 days of skilled nursing home health 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 would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 required moderate assistance to scoot, sit up, lie down, stand up and sit 
down. The enrollee required minimal assistance/contact guard assistance to walk 34 feet using a rolling walker. 
The documentation does not support that the enrollee requires 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. 
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography. 
 
You asked the Plan to pre-approve transthoracic echocardiography. You say that you would like 
reconsideration because this diagnostic testing is needed to evaluate left ventricular function after 
revascularization. The Plan denied your request. The Plan says transthoracic echocardiography is considered 
medically necessary for reevaluation within six months following a revascularization. 
 
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 transthoracic echocardiography. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the test exceeds the member's medical needs at this time. There are no 
documented procedural complications, no documented myocardial infarction, no documented recurrent cardiac 
symptoms and a recent normal cardiovascular physical exam. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transthoracic echocardiography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transthoracic echocardiography.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued stay at a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the continued stay at a SNF. You say that you need continued SNF care. 
The Plan denied your request. The Plan says there are no noted skilled nursing or therapy needs that need to be 
provided on a daily basis. 
 
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 continued stay at a SNF. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no 
identifiable skilled nursing service needs or no identifiable skilled therapy service needs. Furthermore, our 
doctor also found that the beneficiary does not require skilled nursing or therapy services on a daily basis and 
the beneficiary does not meet severity of illness or 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 continued stay at a SNF. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continued stay at a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy. 
 
You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration 
because the additional physical therapy is medically necessary. The Plan denied your request. The Plan says the 
member appears to be at her highest level of function realistically attainable and within the context of her 
condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found There is no documentation that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist or under the supervision of a therapist.  There is no 
documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to 
establish, design and/or deliver a program to maintain the member's current condition or to prevent or slow 
further deterioration. 
 
 
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 additional physical therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional tooth extractions. 
 
You asked the Plan to pre-approve additional tooth extractions. 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 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. 
 
Review of the file shows that you are requesting additional tooth extractions. The plan has already approved 
two extractions. Your contract with the plan only covers two extractions per calendar year. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve additional tooth 
extractions.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that the enrollee is having surgery and will be non-
weight bearing. The Plan denied your request. The Plan says that the documentation did not show why the 
enrollee cannot use standard durable medical equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 a knee scooter. Our physician reviewer 
found that the enrollee has an upcoming orthopedic procedure. He will be non-weight bearing for 6-8 weeks. A 
wheelchair is not practical for someone who can use a knee scooter. Therefore, the requested knee scooter is 
indicated, and medically reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a knee scooter have been met. Therefore, we decided that the Plan has to pre-
approve a knee scooter.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSinuva (C9122).You asked the Plan to pre-approveSinuva. You say that Sinuva is medically necessary.The Plan denied your request. The Plan says the drug requested is not indicated to treat the enrollee's condition.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Sinuva. Our reviewer says that Sinuva is not medically necessary. Our physician reviewer found the Sinuva sinus implant is indicated for the treatment of nasal polyps in patients who have had ethmoid sinus surgery. The documentation does not support that the enrollee in this case has nasal polyps.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of Sinuva have not been met.Therefore, we decided that the Plan does not have to pre-approveSinuva (C9122).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital services you received from April 25, 2020, to May 6, 2020.You asked the Plan to waive the copayment forthe inpatient hospital services. You say that these charges were extreme and you didn't have a CT scan when you were in the hospital.The Plan denied your request. The Plan says you were charged this copayment 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 $300 copayment per day for days 1-5 for inpatient hospital care. Records show that you were in the hospital for 11 days.  You have been asked to pay a $300 copayment per day for days 1-5 for the inpatient hospital services for a total of$1500. 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 forthe inpatient hospital services you received from April 25, 2020, to May 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 massage therapy visits. 
 
You asked the Plan to pre-approve 12 massage therapy visits. You say that the letters from your primary are 
physician and neurologist explain why you need massage therapy. You say that you have multiple sclerosis and 
need massage therapy to be able to function. The Plan denied your request. The Plan says the services are 
denied. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve 12 massage therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health care from November 
12, 2020, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this patient does not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 
12, 2020, forward as this patient was not shown to be a danger to themselves or others. The patient was not 
showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing 
any threats the safety. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient mental health care from November 12, 2020, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultraviolet light therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical necessity of this request cannot be established. 
 
The Plan must follow Medicare rules. Medicare rules say that ultraviolet light therapy is covered for patients 
with generalized intractable psoriasis. 
 
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 therapy. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee disseminated vitiligo. The enrollee does not have the covered diagnosis for the 
requested therapy - generalized intractable psoriasis. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultraviolet light therapy for the enrollee.