Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient admission for a laparoscopic hysterectomy and 
sling procedure. 
 
You asked the Plan to pre-approve the inpatient admission. You say that the records provided support the need 
for inpatient hospital care. The Plan denied your request. The Plan says that the records do not show how the 
approved surgery is expected to be more complex, or why an outpatient/ambulatory level of care would not be 
appropriate. 
 
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 pre-approve the inpatient admission. Our reviewer 
says that the documentation supports that the criteria for inpatient coverage are met in this case. Our physician 
reviewer found the record indicates that the enrollee is scheduled for a laparoscopic hysterectomy and sling 
procedure. The record also indicates that the enrollee, who is legally blind, underwent re-do rectopexy and 
sigmoid resection which makes the procedure more complex and had considerable pain post procedure. The 
totality of the record indicates a reasonable expectation of a two midnight stay. The elements of the coverage 
rule are satisfied. 
 
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 inpatient admission have been met. Therefore, we decided that the Plan has 
to pre-approve acute inpatient admission for a laparoscopic hysterectomy and sling procedure.  
 
 
 
 
 
 
 
 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered as you don't agree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services 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). Your contract with the Plan clearly says that you must pay a $20 
copayment for Outpatient rehabilitation services.  
 
 
  You have been asked to pay a $20 copayment for the physical therapy services. Physical therapy services fall 
within the Outpatient rehabilitation services benefit category. 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 physical therapy services provided on
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient Wound care procedures on July 
22, 2021 to August 19, 2021. 
 
You asked the Plan to waive the copayments for outpatient Wound care procedures. You say that you believe 
your services should be covered. The Plan denied your request. The Plan says the copayments you are being 
charged are correct. 
 
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 $225 
copayment for each outpatient Wound care procedure. The allowed amount of each procedure is $138.47, 
resulting in a total copayment amount of $692.35 because this is less than the $1,125 total copayment for your 
five visits. 
 
You have been asked to pay a $225 copayment for each outpatient Wound care procedure. Wound care falls 
within the Outpatient Hospital Services benefit category. 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 copayments for outpatient Wound care 
procedures on July 22, 2021 to August 19, 2021.
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 enrollee needs IRF in order to improve and return 
home sooner. The Plan denied your request. The Plan says the enrollee's ongoing skilled therapy and nursing 
needs can be provided at a lower level of care such as at a Skilled Nursing Facility, on an intermittent basis at 
home with home health care, or in a long-term care 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 in the Medicare rules section. 
 
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. 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. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of 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. 
 
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 pay a separate payment for an inpatient readmission provided from 
September 1, 2021, through September 21, 2021. 
 
 
 You asked the Plan to pay for a separate payment for the inpatient readmission. The Plan denied your request. 
The Plan says the member was admitted to the hospital on August 23, 2021, through August 29, 2021 for 
congestive heart failure (CHF) and readmitted to the same hospital for CHF on September 1, 2021. For this 
reason, the current request for a separate inpatient admission will be denied. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 a separate payment for the inpatient 
readmission. Our reviewer says that that inpatient readmission is not medically necessary. Our physician 
reviewer found that the enrollee is a 72-year-old female who was readmitted to the hospital with shortness of 
breath and right-side chest pain following discharge 2 days prior for acute on chronic CHF, chronic obstructive 
pulmonary disease exacerbation. Bumex was stopped on discharge, and she didn't follow-up with her primary 
care physician soon after discharge to manage her CHF. This second admission appears to not be medically 
necessary as the enrollee was not significantly hypoxic and only required short-term lower level of care 
management. Based on the documentation, the readmission was directly related to lack of complete treatment 
on recent discharge. 
 
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 separate payment for the inpatient readmission. have not been met. Therefore, 
we decided that the Plan does not have to pay a separate payment for an inpatient readmission provided from 
September 1, 2021, through September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance Durable Medical Equipment (DME) on 
August 2, 2021 to November 2, 2021. 
 
You asked the Plan to waive the coinsurance Durable Medical Equipment (DME). You say that you would like 
to dispute the amount charged. The Plan denied your request. The Plan says the 20% coinsurance you are being 
charged is correct. 
 
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 Durable Medical Equipment (DME). The total allowed amount of the Durable Medical 
Equipment provided is $686.40, resulting in a coinsurance amount of $85.80. 
 
You have been asked to pay 20% coinsurance for Durable Medical Equipment (DME). Durable Medical Equipment (DME) falls within the Durable medical equipment (DME) and related suppliesbenefit category. 
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 Durable Medical Equipment (DME) on August 2, 2021 to 
November 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you feel that this should be covered. The 
Plan denied your request. The Plan says you do not meet criteria for SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who 
underwent a right total knee replacement. From a nursing perspective, the beneficiary received oral 
medications and insulin. The beneficiary had stable vital signs. She was treated for pain. Regarding 
rehabilitation services, the beneficiary received physical and occupational therapy. The beneficiary was at a 
standby assist level for functional mobility including gait to 200 feet. The beneficiary required varying assist 
with daily living activities. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, skilled therapy is not required on a daily basis. This 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you live alone and do not have anyone at 
home to assist you. Due to your low reserve and endurance, you require subacute care. The Plan denied your 
request. The Plan says the services you require can safely be received at a different setting, for example, home 
with home health, in residential care, or home with close follow-up with your doctor. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male with 
interstitial lung disease. From a nursing perspective, the beneficiary received oral medications. The beneficiary 
had stable vital signs. He used oxygen via nasal cannula. Regarding rehabilitation services, the beneficiary 
received physical and occupational therapy. The beneficiary was at a supervision/stand by assist to contact 
guard assist level for functional mobility including gait to 100 feet with a rolling walker. The beneficiary 
required varying assist with daily living activities. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, these are not required on a daily basis. This 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: 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 your medical needs are too complex to be managed 
at a SNF facility. The Plan denied your request. The Plan says your needs can be 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 in the Medicare rules section. 
 
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 that the complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you have a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
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 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 enrollee requires medical oversight due to 
multiple sclerosis and pain related to rib fractures. The Plan denied your request. The Plan says care could be 
received 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 in the Medicare rules section. 
 
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 rib fractures after a fall. 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. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is still not fully functional and 
is unable to walk at this time. They are at risk of losing maximum function of their legs. The Plan denied your 
request. The Plan says the enrollee's acute rehabilitation treatment has been completed, and intermittent skilled 
services can be safely received in a lower level of care.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female with a 
history of stroke and gastrointestinal bleeding. From a nursing perspective, the beneficiary received oral 
medications and had stable vital signs. Regarding rehabilitation services, the beneficiary received physical, 
occupational, and speech therapy. The beneficiary was at maximal assist to moderate assist level for functional 
mobility. The beneficiary required varying assist with daily living activities.  
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, skilled therapy is not required on a daily basis. This 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 18, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that a home visit provider advised the 
enrollee to go the emergency due to blood pressure results. The Plan denied your request. The Plan says the 
enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for each emergency room visit.  
 
The enrollee has been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 
Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. 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 an emergency room 
(ER) visit provided on June 18, 2021.