Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 14, 2021, to 
November 19, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that prior authorization was not obtained within 24 
hours of the admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the provided documentation indicates that the enrollee was admitted to the intensive care unit 
(ICU) and intubated for the first 24 hours. The reviewer found that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. 
Therefore, the reviewer found that the inpatient admission was 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from November 14, 2021, to November 19, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 pressure mattress. 
 You asked the Plan to pre-approve the requested item. You say that a regular bed gave the enrollee bed sores. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that pressure reducing support surfaces are only covered 
under certain medical indications.  
 
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 item. Our physician 
reviewer found that in this case, the enrollee has limited mobility due to her medical condition. The 
documentation does not support that she has multiple stage 2 pressure ulcers located on the trunk or pelvis or 
has failed to improve in the previous month with conservative treatment with a comprehensive ulcer treatment 
program or a myocutaneous flap or skin graft. Therefore, the requested pressure reducing support surface 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 requested item have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a group 2 pressure mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 3, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 physician's services provided on May 3, 2022.
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 are requesting reconsideration appealing the 
denial of skilled nursing facility admission. The Plan denied your request. The Plan says based on Medicare 
guidelines, the skilled nursing facility services you 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were diagnosed with a urinary tract infection and received oral medications. You 
were at supervision/stand by assist to contact guard assist level with functional mobility including gait to 100 
feet. You do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of 
a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our reviewer also found you do not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 2, 2022, and  
March 30, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 physician's services provided on March 2, 2022, and  
March 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for LTACH care. 
 
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 continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that the enrollee is not currently 
receiving but that would be available at the LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycontin. 
 
You asked the Plan to pre-approve Oxycontin. You say that the enrollee has a long history of chronic low back 
pain with radiation into his right leg. You say that the records provided support the need for the requested drug. 
The Plan denied your request. The Plan says the enrollee does not have a pharmacy benefit under this contract. 
The plan says that the enrollee does have Missouri Consolidated Health Care Plan which provides its own 
pharmacy benefits. The Plan says that the enrollee's prescription coverage is provided through Express Scripts. 
 
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 Oxycontin.  
 Benefits for Oxycontin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve neuroablation services. 
 
You asked the Plan to pre-approve neuroablation services. You say that the clinical information provided 
supports the need for neuroablation services. The Plan denied your request. The Plan says that your current 
pain has not been presented for at least 3 months with documented failure of conservative management. The 
Plan says that you have not had diagnostic injections. 
 
The Plan follows Medicare rules. Medicare rules say that the evidence supports RFA as an efficacious 
treatment for lumbar facet joint and sacroiliac joint pain, with five of six and both of the RCTs demonstrating 
statistically significant pain reductions, respectively. 
 
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 neuroablation services. Our reviewer 
says that the criteria for coverage have been met. Our physician reviewer found that you are a 90-year-old man 
with a diagnosis of sacroiliitis, not elsewhere classified. You have degenerative disc disease as well as 
sacroiliac (SI) joint dysfunction, with chronic low back and sacroiliitis. You previously underwent 
radiofrequency ablation (RFA) of the lateral sacral branches in 2013 and had excellent results. The pain 
returned approximately one month ago. The records provided support that the requested neuroablation services 
are medically reasonable and necessary for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuroablation services have been met. Therefore, we decided that the Plan has 
to pre-approve neuroablation services.  
 
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 physician's services provided on April 21, 2022. 
 
You asked the Plan to pay for physician's services. You say that the patient is in a long-term care facility and 
this provider is the rounding physician. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 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 physician's services provided on April 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you have no other means of transportation. 
The Plan denied your request. The Plan says you have utilized your benefit of 10 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 one-way trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 12, 2022, and 
February 10, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service 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 physician's services provided on January 12, 2022, and  
February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EpiFix allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the member has a wound that is in need of 
immediate closure with EpiFix allograft. The Plan denied your request. The Plan says that records do not show 
evidence of chronic wounds that have failed standard treatment for at least a 30 day period. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The enrollee has a history of diabetes mellitus, hypertension, and peripheral vascular disease. The records show a chronic venous 
leg ulcer on the right lower leg which has been treated with wound care at the wound clinic. The detailed 
information on the current status of the leg wound was not sent. The records do not show evidence of chronic 
wounds that have failed standard treatment for at least a 30 day period, a skin deficit at least 1.0 cm2 in size, 
partial or full-thickness ulcers, not involving tendon, muscle, joint capsule or have exposed bone or sinus tracts, 
with a clean granular base that is clean and free of dead tissue. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve EpiFix allograft for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a receiver used with a therapeutic continuous glucose 
monitor (CGM) (K0554) and supply allowance (K0553). 
 
You asked the Plan to pre-approve a receiver and supply allowance for a CGM. You say that the enrollee was 
previously approved for Dexcom, but it was too expensive, and they never got it. The Plan denied your request. 
The Plan says this request for the CGM and supplies is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess 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. Based on this information, we decided that Medicare rules for coverage of a 
receiver and supply allowance for a CGM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a receiver used with a therapeutic continuous glucose monitor (CGM) (K0554) and supply 
allowance (K0553).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you are requesting continued SNF 
services. 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 continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found daily skilled services are not necessary. Our physician reviewer 
found that the medical records do not document that you require services on an inpatient basis, only 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve extended SNF stay.
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 you are requesting reconsideration stating the 
enrollee is needing inpatient rehabilitation due to a stroke and acute respiratory failure. You say that you feel 
the enrollee would benefit from rehabilitation and the goal to get back home and independent. The Plan denied 
your request. The Plan says after an internal medical review it was determined that based on Medicare 
guidelines, the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
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 was admitted for a stroke. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the enrollee has a need for physical 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management services. 
 You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee did not have an 80% improvement in pain. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
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 enrollee has chronic axial cervical pain. The enrollee had a diagnostic set of medial 
branch blocks (MBBs) and achieved 60% pain relief. The request is for a second set of diagnostic MBBs. The 
coverage criteria states that 80% pain relief is the criteria that must be met. Having failed to achieve this level 
of relief, the request is deemed not medically reasonable or 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 pain management services.