Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that the enrollee requires transportation 3 times per 
week for treatment. You also say that the treatment is vital for the health of the enrollee. The Plan denied your 
request. The Plan says additional trips beyond the 20 allowed per year are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided to the enrollee from 
August 7, 2021, to August 10, 2021. 
 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there should be two separate claims, as the enrollee went into the emergency room on 8/7/21 and 
went back on 8/10/21. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 services. Our reviewer says that the services at issue Our 
reviewer found the documentation is not clear on services provided, as the dates do not match the dates of 
service billed. The pages do not clearly document the care for each date of servie billed. In this case, the 
services were billed in correctly. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services provided to the enrollee from August 7, 2021, to August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667, 
E0656) for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no trial of a basic pump. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found as the records do not document failure of a daily four week trial of a standard pump, it cannot be said 
that the enrollee has unique characteristics that would indicate the segmented pump over a standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667, E0656) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued referral for out-of-network dialysis. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says a limited referral was allowed to allow time for the enrollee to transition to a network 
facility. 
 
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 continued referral for out-of-network dialysis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is needed in order to do safe bathing. The 
Plan denied your request. The Plan says this is not covered under the benefit plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 appears to be unstable and requires short-term additional acute care 
services that can be safely completed at the current facility until more stable and/or appropriate for a lower 
level of care. The patient does not require services at the LTACH that are not already  available at the current 
facility. Transfer to LTACH is not medically necessary as the patient is not stable and as it would not be 
clinically advantageous at this time. Completion of treatment at the current facility is recommended. 
 
 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
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. The Plan denied your request. The Plan says the 
enrollee does not require care at the LTACH that cannot be treated in the current hospital. 
 
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 in this case the enrollee was admitted for repair of left ischial decubitus 5 with gluteal 
fasciocutaneous flap secondary to persistent stage four ischial decubitus. The record indicates that the enrollee 
is improving but requires ongoing acute care services before being able to transition to a lower level of care.  
The enrollee continues to receive acute care services and these have not been denied. The medical record does 
not indicate that the enrollee requires services that she is not currently receiving but that would be available at 
the LTACH facility. The elements of the coverage rules are not 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says needs can be met in an assisted living facility with home health services. 
 
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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found there 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. 
 
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 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 admission to a long-term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another 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. Our 
physician reviewer found you appear to be improving and should only require short-term additional acute care 
services that can be safely completed at the current facility until more appropriate for a lower level of care. You 
do not require services at the LTACH that are not already  available at the current facility. Transfer to LTACH 
is not medically necessary as it would not be clinically advantageous at this time. Completion of treatment at 
the current facility is recommended. 
 
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 admission to a long-term acute care hospital (LTACH).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new seat lift chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare requires a face-to-face visit and a physician order within the past six months. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 chair. Our reviewer says that the 
requested item is not medically reasonable or necessary. Our physician reviewer found the records state that 
you are able to "stand with support" but do not clearly state that you are completely incapable of standing from 
a chair in the home. Another part of the record states "you are able to stand up from a regular armchair or any 
chair in the home, without assistance." The records state her "gait is unobserved, is sitting in a motorized 
wheelchair and has difficulty with ambulation." Another part of the record states "once standing, she does not have the ability to ambulate." The prescription order is dated 6/17/21. 
 
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 chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a new seat lift chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 your continued care needs included high flow oxygen to treat the pneumothorax and 
continuation of regular medications. There is no documentation provided indicating medical necessity for 
admission to a LTACH.  You do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively 
only on an inpatient basis. 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent 300/2ML injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says Dupixent is on the self-administered drug list and is excluded from 
coverage under Part B. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent 300/2ML 
injection.  
 
Benefits for the medication 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (CPT code J3245). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug(s): 
Remicade, Inflectra OR infliximab, and Stelara. The Plan states there is no indication the Plan's preferred 
drug(s) would likely be: less effective, and/or cause adverse effects for the enrollee. 
 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 the medication. Our physician reviewer 
found the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya (CPT code J3245).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an admission to a LTACH is medically 
necessary. The Plan denied your request. The Plan says the criteria for a LTACH has not been met. 
 
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 remains hemodynamically unstable for transfer. Additionally, the wound 
care needed does not require daily intervention by a physician. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reclast 5 mg infusions. 
 
You asked the Plan to pre-approve Reclast. You say that this is medically necessary for the enrollee's condition. 
The Plan denied your request. The Plan says the criteria for coverage of Reclast have not been met. 
 
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 Reclast. Our reviewer says that this 
drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found that 
the enrollee is a 79-year-old female with a history of osteoporosis. Her provider has recommended medical 
therapy with Reclast. The review indicates that based on information supplied by the provider the creatinine 
clearance is calculated to be 34 mL/min. Reclast infusions are contraindicated when your creatinine 
clearance is less than 35mL/min. The review has determined that the documentation did not support that 
Reclast is medically reasonable and necessary for the patient. The documentation did not support that Reclast is 
safe and effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reclast have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Reclast 5 mg infusions.
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 an admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the requested services can be provided 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 only physical therapy and occupational therapy are needed. Our doctor found that 
these services could be provided at a lower level of care such as a subacute 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 continued inpatient psychiatric services. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on April 6, 2022 with bipolar-type schizoaffective disorder. There are no records documenting if the enrollee has suicidal or homicidal ideation or auditory or visual hallucinations. There are no records 
documenting that active treatment was taking place. The continued services are not medically necessary based 
on the submitted documentation. 
 
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 continued inpatient psychiatric services.