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

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 admission 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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital with
left foot pain after foot surgery in August of 2021. You received oral medications and insulin and had stable
vital signs. You received physical and occupational therapy in the hospital and need contact guard to stand by
assistance with functional mobility, including gait. You are non-weight bearing on your left leg. You have no
skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a
practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve substance abuse inpatient care from November 22, 2021, forward.

You asked the Plan to pre-approve substance abuse inpatient care from November 22, 2021, forward. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve substance abuse inpatient care from November 22, 2021, forward. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was not going through any withdrawal behaviors and was willing to be involved in treatment. It did not appear medically necessary and reasonable to have psychiatric/detoxification care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of substance abuse inpatient care from November 22, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve substance abuse inpatient care from November 22, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for continuous glucose monitor supplies.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
requested codes are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
The file shows that CPT code A9276 was requested. CPT Code A9276 describe the supplies used with a non-
therapeutic continuous glucose monitor and is non-covered. Based on this information, we decided that
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve for continuous glucose monitor supplies.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that you are being discharged from the hospital
and need more care. The Plan denied your request. The Plan says this request 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 you do not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our
reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge,
and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require
daily skilled nursing and/or skilled therapy on 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 the SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve a skilled nursing facility (SNF) admission
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 the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found you are receiving appropriate care at the present acute care hospital. There are no
services available at the LTACH that you require that are not available at the health care setting being offered
by the health plan.
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: 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 the enrollee has had a long, complicated
hospital course, and would be best served with continued care in an LTACH. The Plan denied your request.
The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically
necessary acute and/or critical care in the current facility. The enrollee does not have clinical conditions that
cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a
therapeutic advantage. The Plan will continue to cover medically necessary acute and critical care at the current
facility until the enrollee is stable for transfer to a lower level of care or until the clinical circumstances change.
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 more stable but still requires additional short-term acute care
services such as PEG use and weaning that can be safely administered at the current facility. The enrollee does
not require services at the LTACH that are not already available and covered at the current facility. Transfer to
LTACH will be considered not medically necessary as it would not be clinically advantageous compared to
completing care at the current facility. Transfer may be considered when the enrollee is more stable and
appropriate for 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 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: 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 inpatient rehabilitation to regain
their strength for radiation treatment. The enrollee cannot get the same care from a nursing facility. The Plan
denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely
receive the services they need in an alternate 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 that 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. 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 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 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 enrollee does require physical therapy and occupational therapy services but
based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy
program. Care at the skilled nursing facility level appears to be 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered when you are not on insulin.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
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 the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 necessitating 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 present setting where she is 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.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan with calcium
scoring.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
service is not medically necessary for the enrollee's clinical condition.
The Plan must follow Medicare rules. Medicare rules say that CT 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 requested services. Our physician
reviewer found that the testing at issue in this appeal was requested as a screening for disease in the heart. Your
risk of developing atherosclerotic cardiovascular disease must be between 5.0 percent and 19.9 percent. The
review has determined that the requested CT scan medically 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a computed tomography (CT) scan with calcium scoring
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 the enrollee will likely require another 3-
4 weeks of acute hospital care and requires transfer to an LTACH. The Plan denied your request. The Plan says
the criteria for admission to an LTACH have not been met. The enrollee's medical needs are being met in the
current acute setting. The LTACH would provide no additional services. With additional time in the current
setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
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 improving with current treatment and should only require
short-term acute care services that can be safely administered at the current facility. The enrollee does not
require services at the LTACH that are not already available and covered at the current facility. Transfer to the
LTACH will be considered not medically necessary at this time as it would not be clinically advantageous.
Transfer to a lower level of care may be considered soon when treatment has completed.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a simple extraction (D7140) and comprehensive oral
evaluation (D0150) to be provided by an oral surgeon.
You asked the Plan to pre-approve dental services to be provided by an oral surgeon. You say that extraction of
this tooth is medically necessary, and you were referred to an oral surgeon to receive treatment. The Plan
denied your request. The Plan says services provided by anyone other than a participating general dentist are
not covered. The requested services are excluded from coverage, as the request is for them to be performed by
an oral surgeon.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Dental services must be
performed by a participating general dentist to be considered for coverage.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services provided by an oral
surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pre-approve a simple extraction (D7140) and comprehensive oral evaluation (D0150) to be provided by an oral
surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Orthofix Trinity Allograft.
You asked the Plan to pre-approve the Orthofix Trinity Allograft. You say that you would like reconsideration
because the requested procedure is medically necessary. The Plan denied your request. The Plan says the
Orthofix Trinity Allograft 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 Orthofix Trinity Allograft. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the Orthofix Trinity Allograft remains experimental when used in surgery
and more research is needed to show its safety and efficacy.
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 Orthofix Trinity Allograft have not been met. Therefore, we decided that the
Plan does not have to pre-approve the Orthofix Trinity Allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be received by an out-of-network
(OON) provider with no coinsurance.
You asked the Plan to pre-approve these OON services to be received with no coinsurance. You say that the
enrollee requires these services. The Plan denied your request. The Plan says the requested services can be
received at the out-of-network at the coinsurance rate.
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. Review of the file shows that you may
receive services from an out-of-network provider; however, you must pay a coinsurance for these services. 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 an office visit to be received by an out-of-network (OON) provider with
no coinsurance