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. You say that the enrollee meets the full IRF criteria based on his 
current condition, functional deficits, and multiple comorbidities. You say that the enrollee requires intensive 
inpatient rehabilitation with daily physician management, 24-hour specialized rehabilitation nursing, and 
intensive therapies to optimize mobility and strengthening while ensure the restoration of functional status for 
safe and sustainable discharge. The Plan denied your request. The Plan says the guidelines for coverage of IRF 
care have not been met. The Plan says that the enrollee could receive the care needed in another 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 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. The enrollee 
was admitted for suicidal ideation an alcohol dependence. The enrollee's medical problems are stable. There are 
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. You say that the enrollee needs services to regain her 
maximum function. The Plan denied your request. The Plan says the enrollee has returned to baseline and does 
not have any skilled 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 continued services. Our physician 
reviewer found that the enrollee was walking 100 feet with stand-by assistance with a front wheeled walker and 
was at contact guard assist for stairs. She was at standby assist for transfers. There are no detailed reports from 
occupational therapy in the available records with regard to her needs with activities of daily living. Reports 
indicate she uses a walker at baseline. There is no report in the records of any medically unstable conditions 
requiring skilled nursing services or treatment with anything other than outpatient medications. There is no 
documentation that the enrollee requires skilled nursing or skilled therapy services on a daily 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair 
 
You asked the Plan to pre-approve the power wheelchair. You say that you require a power wheelchair. The 
Plan denied your request. The Plan says Payment is made for only one wheelchair at a time. Backup chairs are 
denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical 
equipment is no less than five years. Replacement equipment may be granted when irreparable wear or 
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.  
 
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the 
enrollee has received the same durable medical equipment in June 2020. Your request is not medically 
necessary because your records show you are in possession of a power operated vehicle for use inside your 
home which is still under warranty and able to be repaired. There is no documentation that replacement is 
required and that the power wheelchair received in 2020 cannot be repaired. Based on this information, we 
decided that Medicare rules for coverage of the power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is not the standard of care for prostate cancer. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being offered pelvic/prostate bed radiotherapy for salvage therapy. Future 
work is warranted to determine the cost-effectiveness of PBRT and to identify the population best suited for 
this treatment. The need for future study is indicative of the unknown benefit from proton therapy with 
retrospective analyses. While some may argue that it is standard practice to treat prostate cancer with proton 
therapy, both the American Society for Radiation Oncology (ASTRO) and the National Comprehensive Cancer 
Network (NCCN) guidelines recommend against routine use of proton therapy. Coverage for a patient enrolled 
on a clinical trial would be within accepted standards or care. The case file does not show that this enrollee is 
enrolled in a trial. Therefore, the requested services are not medically reasonable or necessary at this time. 
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 proton beam radiation therapy (PBRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system for a power wheelchair. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item still does not meet the coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system for a power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does 
not require skilled nursing or therapy services on a daily basis. The enrollee's needs can be met in 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 skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the care you need appears to be custodial in nature.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an UpWalker. 
 
You asked the Plan to pre-approve an UpWalker. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve an UpWalker.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs complete healing of the 
wound. The Plan denied your request. The Plan says the enrollee no longer requires daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 

Continued SNF services beyond October 16, 2021, were requested. 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 the enrollee is at a 
moderate assist level for transfers and activities of daily living with no significant change in functional status 
documented. Intravenous antibiotics were stopped. The records do not report any ongoing medical issues 
requiring intravenous medications or daily skilled nursing services. Based on the medical records, the enrollee 
does not require skilled nursing or therapy services on a daily basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided on January 27, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth services. You say that these services should be covered. The Plan 
denied your request. The Plan says telehealth services rendered by an OON provider are specifically excluded 
from coverage. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan does not have to pay for telehealth services rendered by an OON provider. 
 
The Plan did not pre-approve the item/service at issue. Specifically, this was a telehealth appointment from an
OON provider where coverage is not allowed. We found no exception that would require the Plan to pay for 
these items/services. Therefore, we decided that the Plan does not have to pay for the telehealth services 
provided on January 27, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series x-ray (D0210) provided on June 1, 2021. 

You asked the Plan to pay for the dental services. You say that when you made your appointment, you were 
advised that the office accepted your insurance. You say that you received a bill a few weeks later. You say 
that the office told you that at the time of your appointment, they did not accept your insurance. You also say 
that you would have gone somewhere else had you known. The Plan denied your request. The Plan says the 
provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental 
services performed by a dentist that has opted out of Medicare. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services are not among those 
covered under this benefit when performed by a dentist that has opted out of Medicare. Therefore, we decided 
that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray 
(D0210) provided on June 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on June 
28, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should only owe a 
$35 copayment not a $205 copayment for outpatient hospital services The Plan denied your request. The Plan 
says the claims were processed correctly and you are being charged the correct amount. 
 
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 a $35 
copayment for each outpatient hospital facility visit and a $205 copayment for outpatient hospital surgical 
services. 
 
The record shows that you received a diagnostic colonoscopy at an outpatient hospital facility on June 28, 
2021. A diagnostic colonoscopy is considered an outpatient surgical procedure. Therefore, you are responsible 
to pay the $205 copayment.  

You have been asked to pay a $35 copayment for a $205 copayment for a diagnostic colonoscopy. A diagnostic 
colonoscopy falls within the outpatient hospital services 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 
the copayment for a diagnostic colonoscopy provided on June 28, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on March 8, 
2020. 
 
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 claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until July 28, 2021. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the emergency room (ER) services rendered on March 8, 2020.
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 services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 not require the intensity of services provided at an 
IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative 
services with regular physician evaluation. 
 
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 skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs therapy and wound care. The 
Plan denied your request. The Plan says skilled services can be provided on an intermittent basis in an 
outpatient 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 services. Our physician reviewer 
found that the enrollee was treated in the hospital with intravenous fluids and medication management and 
stabilized. She has bilateral buttock wounds which are being treated with Xeroform every other day; no surgery 
is required. She is non-ambulatory at baseline and requires a lift device for transfers. She is dependent for most 
activities of daily living. She is reported to be medically stable for discharge on outpatient medications. There 
is no documentation that the enrollee requires skilled nursing or skilled therapy services on a daily basis in a 
SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from August 1, 2020, 
through August 9, 2020, billed with code FAPF1. 
 
You asked the Plan to pay for the SNF services as billed. You say that the Section GG clarification documents 
the overall picture of the enrollee's first three days of the SNF stay. Although the dates are not explicitly stated, 
it is understood that an admission evaluation would refer to these dates. The Plan denied your request. The Plan 
says that the documentation is not sufficient to support the usual functional ability coding for Section GG 
meaning that the billed HIPPS code is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan's denial rationale is not sufficiently specific to justify 
adjustment of the billed HIPPS code. It is noted that the Section GG Clarification cannot be used to justify the 
coding on the Minimum Data Set (MDS) assessment simply because it does not specify the three-day period it 
is referencing. However, as argued by the provider, the three-day lookback period for the reporting of usual 
functional abilities on admission is always the first three days of the admission. Since this document is 
identified as being done as an admission evaluation and reports for the three-day lookback period, it is known 
that this refers to the first three days of the admission. In addition, the Plan has failed to identify any specific 
discrepancy between what is reported on the MDS form and what is documented in the rest of the record. We 
find that adjustment of the physical/occupational therapy and nursing case-mix groups is not supported based 
on the evidence provided. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) 
care provided from August 1, 2020, through August 9, 2020, billed with code FAPF1.  
 
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.