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

 
We decided that the Plan has to pre-approve Pegfilgrastim for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary and beneficial. The Plan 
denied your request. The Plan says that the criteria is not 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 the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found this drug is recommended 
and standard of care for patients whose risk of neutropenic fever is more than 20%. This regimen coupled with 
the enrollee's age being over 65 years old meets this criteria. The use of Pegfilgrastim/Neulasta is reasonable 
and 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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Pegfilgrastim for the enrollee.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 1, 2021 to 
February 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
dates of service at issue. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from February 1, 2021 to February 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee with post-surgery complication - 
thrombus of the left greater saphenous vein would benefit from continued skilled physical therapy services in 
order to improve endurance, functional independence, transfers, stair negotiation and ambulation. The Plan 
denied your request. The Plan says the level of care required for the enrollee's recovery does not require daily 
skilled therapies to help the enrollee return to their prior level of function. The Plan states care the enrollee 
requires, intermittent physical and occupational therapy, can be provided at a lower level of care such as home 
with skilled home health care 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy 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 SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for IRF care is correct. 
 
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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. 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 second opinion office visit to be provided by a 
tertiary level provider. 
 
You asked the Plan to pre-approve the second opinion office visit. You say that you were getting blind quickly. 
You state that you have seen two (2) ophthalmologists and a retina specialist in the past; however, your 
condition was not getting any better. The Plan denied your request. The Plan says your notes do not show that 
you need tertiary level care. 
 
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 second opinion office visit. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that you have the following diagnoses: neovascular 
age-related macular degeneration (AMD) with active choroidal neovascularization (CNV) (left eye), dry AMD 
advanced atrophic with subfoveal involvement (both eyes), posterior vitreous detachment (both eyes) and two 
stable operculated holes sealed with pigment (right eye). The record indicates that the referral to second 
opinion office visit to be provided by a tertiary level provider is enrollee initiated. The record indicates that you 
are receiving medically necessary care. The Plan has indicated there are other providers available to provide the second opinion. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not 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 second opinion office visit have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the second opinion office visit to be provided by a tertiary level provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for medical services provided to the enrollee on April 15, 2021. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on April 
15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network medical services provided to the enrollee 
from May 24, 2021, to May 26, 2021. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for out of network medical services provided to the 
enrollee from May 24, 2021, to May 26, 2021.
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 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 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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you are receiving adequate and necessary intensive rehabilitation in the 
Inpatient Rehabilitation Facility. 
 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Other
Decision: Favorable

We decided that the Plan has to pay for the diagnostic vision services (92134) you received on May 27, 2021. 
 
You asked the Plan to pay for the services. You say that you had an approval for these services. The Plan 
denied your request. The Plan says that either the services performed, the servicing provider, or the number of 
visits billed do not match was is approved on the authorization. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The submitted documentation shows an authorization for diagnostic vision care 
with the provider in question. The Plan has not provided documentation showing that the services provided 
were different from the authorized services. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the diagnostic vision services (92134) you 
received on May 27, 2021.  
 
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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
  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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. 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: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services billed with Patient Driven 
Payment Model (PDPM) score MKUF1 x 31 days and MKUF1 x10 days provided July 1, 2020 to July 31, 
2020. 
 
You asked the Plan to pay for the skilled nursing facility (SNF) services billed with PDPM score MKUF1 x 31 
days and MKUF1 x10 days. You say that you would like the plan to reconsider their denial The Plan denied 
your request. The Plan says that PDPM score billed is not supported by the documentation. 
 
The Plan follows Medicare rules. Medicare rules say that SNF services should be billed with the appropriate 
PDPM score. 
 
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 the skilled nursing facility (SNF) services 
billed with PDPM score MKUF1 x 31 days and MKUF1 x10 days. Our reviewer says that the documentation 
does support that the services billed are supported by the documentation. Our physician reviewer found the 
enrollee multiple medical problems, including stroke, vascular encephalopathy, and seizures. A Speech 
Therapy Progress Note dated June 30, 2020 documents that the enrollee appears best with pureed solids and is 
tolerating thin liquids. The admission assessment dated July 7, 2020 documents that the enrollee is dependent 
for eating. The documentation supports the need for a mechanically altered diet (pureed) for this enrollee. 
Therefore, the documentation supports the billing of PDPM score MKUF1 x 31 days & MKUF1 x10 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 skilled nursing facility (SNF) services billed with PDPM score MKUF1 x 
31 days and MKUF1 x10 days have been met. Therefore, we decided that the Plan has to pay for the skilled 
nursing facility (SNF) services billed with Patient Driven Payment Model (PDPM) score MKUF1 x 31 days 
and MKUF1 x10 days provided July 1, 2020 to July 31, 2020.  
 
 
 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from 
April 16, 2021, to May 17, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  

The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider from April 
16, 2021, to May 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says your request does not show you have skilled nursing or therapy needs that need to 
be provided on a daily basis as an inpatient only status. The Plan states 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there is no documentation that you require 
skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are 
not required to safely and effectively provide medically necessary and reasonable treatment. You do require 
skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required 
to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not 
required. You do not require the services on an inpatient basis, only in a SNF setting. Services in a long-term 
care facility on a part time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. The enrollee appears to be functioning at/near their baseline. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollee's 
condition. The enrollee's care needs are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.