Persius/hicric huggingface dataset:
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 SNF services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 here are no identifiable skilled nursing service needs. The enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria are not met.  
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve surgery 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 
surgery services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right shoulder arthroscopy. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has shoulder pain. The 
records do not document a physical exam with positive findings for shoulder pathology. There are no 
documented positive exam findings to indicate surgery. The requested procedure is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right shoulder arthroscopy.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve companionship services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee forgets to eat or bathe at 
times. The Plan denied your request. The Plan says home health aide services to provide companionship is not 
a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care is not covered.  
 
We looked at the file, and Medicare rules. Care with walking, getting in and out of bed, bathing, dressing, 
feeding, and using the toilet are not covered by Medicare. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve 
companionship 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 IRF admission is necessary. The Plan denied your 
request. The Plan says Medicare coverage criteria for IRF admission are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records you do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the record supports a need for physical and occupational therapy, it does not support a need for an 
intensive rehabilitation therapy program. There is no documentation that any physical or occupational therapy 
has been provided thus far in the home setting. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says your care can be provided and managed with the primary network. 
 
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 
the medical services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of prostate 
cancer. The use of proton beam therapy is not routinely recommended for prostate cancer outside of a 
prospective clinical trial or registry. To date, there is no compelling data to suggest that proton beam therapy is 
superior to or more beneficial than intensity modulated radiation therapy (IMRT) or image-guided radiation 
therapy (IGRT). Proton beam therapy is not the standard of care and is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve laser treatment (a procedure that applies light therapy to a specific 
area of the body) x six (6) over sixty (60 months (CPT Code 96999). 
 
You asked the Plan to pre-approve the services. You say that without the treatment the member's pain levels 
will not improve. The Plan states the sight of heal of foot prevents normal function when walking and bearing 
weight due to current problems. The Plan denied your request. The Plan says that it's clinical value and 
effectiveness has not yet been established in the peer-reviewed medical literature. 
 
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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found excimer treatment of inflammatory skin dermatoses like lichen planus in the palmar-plantar 
skin locations is a standard 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve laser treatment (a procedure that applies light therapy to a specific area of the body) x six (6) over 
sixty (60 months (CPT Code 96999).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane (J9264). 
 
You asked the Plan to pre-approve Abraxane. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the member does not meet the clinical 
criteria for coverage. 
 
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 Abraxane. Our reviewer says that the 
information submitted for review does not indicate whether or what treatment the member has had for 
metastatic disease. Our physician reviewer found it is not possible to determine if the requested use meets FDA 
or compendium recommendations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abraxane (J9264).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided from February 2, 2018 through 
March 2, 2018. 
 
You asked the Plan to pay for the medical services. You say that timely filing requirements should be waived.  
You said that you have tried to submit these claims multiple times. The Plan denied your request. The Plan says 
you did not file your claim timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until May 21, 2019. This means that more 
than one calendar year from the date of service had passed before the first time a claim was filed for these dates 
of service. Therefore, we decided that the Plan does not have to pay for medical services provided from 
February 2, 2018 through March 2, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a total electric hospital bed rented on March 27, 2020. 
 
You asked the Plan to pay for a total electric hospital bed. You say that this bed is medically necessary. The 
Plan denied your request. The Plan says total electric hospital beds are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed 
rented on March 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided 
December 13, 2019 to December 23, 2019. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $285 copayment per day for days 1-7 for inpatient hospital care.  
 
The enrollee has been asked to pay a $1,995 copayment ($285 x 7 days) for the inpatient hospital care 
provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. Additionally, the record shows that payment was issued to the provider in the amount of $1,000. 
Therefore, the enrollee's balance owed for this service is $995.00. This cost sharing is a contractual obligation 
the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to 
waive the copayment for the inpatient hospital care provided December 13, 2019 to December 23, 2019.  
 
Your complaint about the enrollee's care received during his initial hospital stay is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse $148 for a rheumatology office visit on January 24, 2020. 
 
You asked the Plan to reimburse this cost share. You say that you were told this doctor took your insurance and 
your copayment would be $40. When you got to the office, they told you they did not take your insurance.  
You believe the Plan should reimburse you the $148 you paid out of pocket. The Plan denied your request. The 
Plan says your provider has not submitted a claim for payment. Without a claim submitted by the provider, the 
Plan cannot process and pay for this service through Medicare. Unless your provider submits s claim, the Plan 
cannot reimburse you.  
 
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 says that you pay a $40 copayment for 
out of network specialist services. However, your provider must submit a claim for payment in order for the 
Plan to pay its share and assess your $40 copayment. Until and unless this is done, the Plan is not required to 
reimburse you for these services. Therefore, we decided that the Plan does not have to reimburse $148 for a 
rheumatology office visit on January 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to start rehab. The 
Plan denied your request. The Plan says admission to a LTACH is not medically necessary, and does not meet 
criteria. 
 
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 does not require any services at the LTACH that are not already 
available at the current facility. Our reviewer found that there are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Our physician reviewer also found 
that transfer to a lower level of care may be considered when the enrollee is more stable, and finished with 
acute care services which will likely take less than 25 days. 
 
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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug has not met step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that the 
documentation does not support that the requested Our physician reviewer found the enrollee has a history of 
osteoarthritis of the knees. The documentation does not support that the enrollee has tried and failed Orthovisc 
and Monovisc. There is no documetnation provided indicating that Orthovisc and Monovisc would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
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's quality of life will be severely 
impacted without rehab services. The Plan denied your request. The Plan says it is not reasonable to expect the 
enrollee will be able to fully benefit from the intensity of an IRF. 
 
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 was admitted for surgical treatment of a hip fracture. All medical problems are stable. 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. There is not a reasonable expectation 
that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. While the record supports a need for physical and occupational therapy, it does 
not support a need for an intensive rehabilitation therapy program. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a non-participating provider. 
 
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 services are available from network providers. 
 
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 
a referral to a non-participating provider.