Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says you do not require an 
intensive multidisciplinary approach to daily therapy. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for lumbar spinal surgery. Your medical problems are stable. 
You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While you 
have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that this care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 based on the medical records provided there is 
no documentation that the patient requires skilled nursing services. The records do not document the need for 
intravenous medications, new tube feeding, or ostomy care or daily complex wound care. While this patient 
does require skilled therapy services, there is no documentation that daily skilled therapy services are required. 
The patient is walking household distances with a rolling walker with contact guard assistance and is contact 
guard assist for transfers. Provided records do not document a significant decline in the patients functional 
status to necessitate daily inpatient skilled therapy services. In conclusion, there is no documentation that the 
patient requires the services on an inpatient basis, only in a skilled nursing facility setting. Records do not 
document those services in the home with home health care or in a long-term care facility on a part time basis 
are not 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 admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing of Jak2 exons 12 and 13. 
 
You asked the Plan to pre-approve genetic testing of Jak2 exons 12 and 13. You say that the requested testing 
is medically necessary to properly diagnose and treat the patient. The Plan denied your request. The Plan says 
the guidelines for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing of JAK2 exon 12 is covered when 
certain criteria are met and when 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 genetic testing of Jak2 exons 12 and 13. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the case file 
does not contain documentation that JAK2 V617F mutation analysis was previously completed and was 
negative 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing of Jak2 exons 12 and 13 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genetic testing of Jak2 exons 12 and 13.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit, and diagnostic radiology 
provided on December 30, 2021. 
 
You asked the Plan to pay for an office or other outpatient visit and diagnostic radiology. The Plan denied your 
request. The Plan says Medicare guidance says only manual manipulation of the spine to correct subluxation is 
covered. All services other than manual manipulation of the spine for treatment of subluxation of the spine are 
excluded when ordered or performed by a Doctor of Chiropractic (DC). 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for office or other outpatient visit, and diagnostic radiology provided on 
December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a routine eye exam. 
 
You asked the Plan to pre-approve a routine eye exam. You say that you are having trouble with your vision 
and need an eye exam. The Plan denied your request. The Plan says you will exceed the frequency limit for this 
service. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once every two plan years. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that a routine eye exam 
was previously covered on August 10, 2020. Based on this information, we decided that the Plan's frequency 
limit for coverage of a routine eye exam would be exceeded with the requested service. Therefore, we decided 
that the Plan does not have to pre-approve a routine eye exam.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any 
documented skilled nursing or skilled therapy needs. 
 
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 care have not been met. Specifically, medically necessary services can 
be obtained in a lower level of care. This means admission into a SNF is not medically necessary. Therefore, 
we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1833) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a knee orthosis. You say that this device should be covered regardless of 
network status. The Plan denied your request. The Plan says there are in-network providers that would be able 
to provide the device in question. 
 
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 knee orthosis (L1833) to be provided by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says there are no 
daily skilled therapy or nursing needs. 
 
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 physician reviewer 
found that you are at an independent assist level for eating and grooming, supervision for bathing, dressing, and 
toileting, and standby assist for walking using a two-wheeled walker. You do not have documented skilled 
nursing or skilled therapy needs. You are ambulating more than 100 feet and tending to activities of daily living 
with minimal supervision. Your care needs, custodial and intermittent. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will be discharged from the hospital and 
need to return to rehab to gain strength and ability to participate in physical therapy and activities of daily 
living. You say that you are requesting rehabilitation to ensure a successful and safe recovery. The Plan denied 
your request. The Plan says the enrollee does not have the medical complexity or intensive rehab needs 
required to 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 that no rehab nursing needs were identified or documented in the record. While the 
enrollee may benefit from physical and occupational therapy, her rehab needs can be addressed in an alternate 
setting such as 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on September 24, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that CPT codes describing anesthesia services (00100-
01999) or services that are bundled into anesthesia. 
 
We looked at the file and Medicare rules. The file shows that procedure code 64772 was billed by an 
anesthesiologist. This code is not covered when billed by an anesthesiology provider. Therefore, we decided 
that the Plan does not have to pay for the surgical services rendered on September 24, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF 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 SNF care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs, though monitoring of your wounds even if the dressings are not changed daily is reasonable. You do 
have documented skilled therapy needs. You are a new amputee in need of training for safety and 
compensatory mechanisms. Daily skilled services are required to establish a maintenance program or to prevent 
deterioration of your condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
 
 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: 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 SNF care. You say that SNF care is medically reasonable and necessary. 
The Plan denied your request. The Plan says the rules for SNF care have not been met. 
 
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 based on the documentation provided you 
do not have documented skilled nursing needs. In addition, you do not have documented skilled therapy needs. 
You are consistently ambulating more than 100 feet and tending to activities of daily living with minimal 
supervision. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of your condition. At this point, your 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 admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive coinsurance for the aflibercept injection provided on 
December 15, 2021. 
 
You asked the Plan to waive coinsurance for aflibercept injection. You say that you have received these 
injections before and have not paid over $30. You say that you are on a fixed income and cannot afford this. 
The Plan denied your request. The Plan says coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs 
(including certain drugs that are used with nebulizers, insulin pumps, and IV infusion pumps).  
  You have been asked to pay $367.18, which is 20% of the allowed amount for aflibercept injection. The 
allowed amount is $1,835.88 (20% x $1,835.88 = $367.18). Aflibercept injection falls within the Medicare 
Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive coinsurance for the aflibercept 
injection provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (L1820). 
 
You asked the Plan to pre-approve the orthosis. You say that you are appealing the denial for the knee brace 
because the enrollee has decreased range of motion. The Plan denied your request. The Plan says the records do 
not support the enrollee meets the Medicare criteria. 
 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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records do not document weakness or deformity of the knee or the need for 
stabilization as required by the LCD. The provided examination note of 02/24/2022 reports no bony or soft 
tissue deformity, normal quad and hamstring strength and no joint laxity on testing. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the knee orthosis (L1820).
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 requires another 3-4 weeks 
of ventilator management and LTACH is medically necessary for the enrollee to transition from his acute 
illness. The Plan denied your request. The Plan says criteria for LTACH services have not been met and the 
enrollee's medical needs are being met in the current acute 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 that services can be obtainable 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the arthrocentesis and betamethasone acetate 
injection that was provided on February 15, 2022. 
 
You asked the Plan to waive the cost share for arthrocentesis and betamethasone acetate injection. You say that 
you do not owe this bill because you have hit your maximus out-of-pocket amount. The Plan denied your 
request. The Plan says the cost share is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare part B covered drugs at an in-network specialists office and $25 copayment for 
surgery services at an in-network specialists office.   
You have been asked to pay a total of $26.36 for the arthrocentesis and betamethasone acetate injection. 
 
Service Allowed Amount Standard Cost Member Liability 
Arthrocentesis $43.32 $25 $25 
betamethasone acetate 
injection 
$6.78 20% $1.36 
TOTAL:   $26.36 
 
Arthrocentesis and betamethasone acetate injection falls within the Medicare Part B prescription drugs and 
Physician/Practitioner services, including doctors office visits benefit category. The records show at the time 
of this service your out-of-pocket maximum was not met. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share 
for the arthrocentesis and betamethasone acetate injection that was provided on February 15, 2022.