Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve readmission for skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve readmission for SNF care. You say that the requested readmission for SNF 
care is medically necessary. The Plan denied your request. The Plan says the requested readmission for SNF 
care does not meet criteria. 
 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 readmission to SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee was ambulating 
100 feet on February 18, 2022. The case file does not contain a physical therapy (PT)/occupational therapy 
(OT) evaluation during her most recent admission. The documentation does not contain documentation that the 
enrollee requires skilled therapy services on a daily basis on an inpatient basis in a skilled nursing 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 readmission to SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve readmission for skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT), 
multiple studies, at rest and/or stress (78452). 
 
You asked the Plan to pre-approve the SPECT study. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage of this service are not met and therefore this service 
is 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 the SPECT study. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is being evaluated for shortness of breath. Her EKG 
(electrocardiogram) demonstrated sinus bradycardia. There is no specific clinical rationale for the requested 
myocardial perfusion imaging, tomographic (SPECT), multiple studies, at rest and/or stress (78452). The 
review has determined that the requested study does not meet the criteria for coverage and is not medically 
necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SPECT study have not been met. Therefore, we decided that the Plan does 
not have to pre-approve myocardial perfusion imaging, tomographic (SPECT), multiple studies, at rest and/or 
stress (78452).
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 requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Although further rehabilitation services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing 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 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 IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need the most intense physical therapy you are able to get. You will not receive enough care at a care home. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage.
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 documentation doesn't support that you meet criteria for admission to an acute inpatient rehabilitation facility. You can receive services at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue exam (88305) and decalcification procedure
(88311) provided on July 20, 2021.
You asked the Plan to pay for the tissue exam and decalcification procedure. You say that this patient was not
enrolled in hospice on July 20, 2021. The Plan denied your request. The Plan says Original Medicare would be
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal
condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 19, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the tissue exam (88305) and decalcification procedure (88311) provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine Pamoate caplet 25mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that The Plan denied your request. The Plan says this medication was denied due to benefit exclusion.
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 Hydroxyzine Pamoate caplet 25mg for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you need physical therapy in a structured setting in order to return home safely. The Plan denied your request. The Plan says your records do not show that you require daily skilled services that can only be provided on an inpatient basis. The services you require, such as additional therapy services, can safely be provided in an alternate setting.
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 that you do not have identifiable skilled nursing service needs which would require the specialized skill, knowledge and judgement of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. You do have skilled therapy needs; however, you do not require skilled nursing or skilled therapy services on a daily basis. As a practical matter, you do not meet the 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix blood glucose test strips. 
 
You asked the Plan to pre-approve True Metrix blood glucose test strips. You say that these are medically 
necessary. The Plan denied your request. The Plan says that there was no documentation provided to support 
the medical necessity of a non-LifeScan product. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file does not include any documentation from your physician 
documenting why you require this specific brand of blood glucose test strips. Without this, medical necessity 
cannot be established. Therefore, we decided that the Plan does not have to pre-approve True Metrix blood 
glucose test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this is medically necessary. The 
Plan denied your request. The Plan says that total electric hospital beds are not covered by Medicare. 
 
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 pre-approve a total electric hospital 
bed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on March 29, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you cannot believe that the ambulance 
company is out of network. You also say that you cannot confirm the ambulance being there. The Plan denied 
your request. The Plan says since no transport was provided, there is no payable service. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 29, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on March 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enoxaparin for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication is denied as a benefit exclusion. 
 
 
 
 
 
 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 Enoxaparin for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF services. 
 
You asked the Plan to pre-approve continuation of SNF services. The Plan denied your request. The Plan says 
based on Medicare guidelines, the SNF services you and/or your provider are requesting do not meet the 
requirements for approval. 
 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 continuation of SNF services. Our 
reviewer says that daily skilled services are not medically necessary. Our physician reviewer found from a 
nursing perspective, you received oral medications. You had stable vital signs. Your lungs were clear. 
Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT) in the 
SNF. By the dates in question, you were at a standby assist to contact guard assist level with functional 
mobility including gait to 300 feet with a rolling walker. You required varying assist with activities of daily 
living and declined recent OT. There are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do 
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 continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of SNF services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darifenacin 7.5mg tablet. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says drug coverage is limited to those covered under the medical benefit. 
 
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 Darifenacin 7.5mg tablet.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer device. 
 
You asked the Plan to pre-approve the Vertiflex interspinous spacer device. The Plan denied your request. The 
Plan says this is not medically reasonable and 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 the Vertiflex interspinous spacer 
device. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed. 
 
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 Vertiflex interspinous spacer device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prochlorper tablet 10mg. 
 
You asked the Plan to pay for the drug. You say that this is medically necessary. The Plan denied your request. 
The Plan says this is denied as a benefit exclusion. 
 
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 pay for Prochlorper tablet 10mg.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiopharmaceutical localization of tumor, 
inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool 
imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis), single day 
imaging (CPT code 78803), for the enrollee. 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says in this setting a repeat MPI stress test, compared to for example intensified anti-anginal 
therapy or cardiac catheterization, has not been established as standard of care towards improved cardiac 
outcomes; therefore, given the provided documentation, the enrollee does not meet the guidelines for the 
requested service which does not appear medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 service. Our physician reviewer 
found PET is not supported in this clinical situation as the enrollee has not had any ventricular ectopy and they 
had not yet had catheterization and magnetic resonance imaging (MRI) to further evaluate the enrollee's 
condition which is standard of care. There is insufficient evidence in the literature to show PET leads to 
improved outcomes including MI, death. Therefore, without sufficient support made for this request, the PET 
will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiopharmaceutical localization of tumor, inflammatory process or distribution of 
radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic 
(SPECT), single area (eg, head, neck, chest, pelvis), single day imaging (CPT code 78803), for the enrollee.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require at least 3 hours a day/ 5 days a week, or 15 hours over 7 consecutive days, of therapy services. 
The enrollee can participate in therapy services, but these 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 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 home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee is still at her daughter's house. The 
Plan denied your request. The Plan says this service can be provided in the 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
home health services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on November 11, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 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 laboratory services rendered by the out-of-network (OON) provider on November 11, 2021.