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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you desperately need to rest in a facility with the 
proper care. The Plan denied your request. The Plan says your records do not show that you require skilled 
services on a daily basis, nor that the skilled services can be provided only on an inpatient basis in a SNF. 
 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 received physical and occupational therapy. You were at maximal assist level 
with bed mobility. You required varying assist with activities of daily living. 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 that 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 SNF care.
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 IRF admission criteria. The Plan 
denied your request. The Plan says based on Medicare guidelines, the requested IRF services 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 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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy 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 skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is ready for the next level of care. 
 
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 there are no identifiable skilled nursing service needs. The enrollee does not require 
skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing home health services (G0299). 
 
You asked the Plan to pre-approve skilled nursing home health services. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not need skilled care. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing home health services. 
Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the 
enrollee does not have documented skilled nursing 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 skilled nursing home health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing home health services (G0299).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says criteria for admission to SNF have not been met. Skilled services can be provided on an 
intermittent outpatient basis. 
 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 that 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. 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 the inpatient hospital care provided from November 11, 
2021, through November 15, 2021. 
 You asked the Plan to pay for the inpatient hospital care. You say that this should be paid because you 
attempted to obtain authorization for the stay which was cancelled by the Plan twice. The Plan denied your 
request. The Plan says the claim does not accurately reflect the number of days for this admission. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit the number of covered 
days on the bill for inpatient care. Field 46 is used to enter this number.   
 
We looked at the file and Medicare rules. The claim as reviewed by Maximus listed the number of units for the 
room/board revenue code as 3. The date range, however, which includes the admission ate but not the 
discharge date is four days. The claim does not indicate any reason that 3 units should be reported for this four-
day stay. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital care 
have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care 
provided from November 11, 2021, through November 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow transplant from an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has more support near this provider 
to undergo the treatment. The Plan denied your request. The Plan says the services are available from network 
providers. 
 
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 bone marrow transplant from an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
entire body. 
 
You asked the Plan to pre-approve a PET scan. You say that the scan is medically necessary. The Plan denied 
your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the reviewed documentation indicates that the 
enrollee has a history of T2 N3 stage IIIC invasive ductal carcinoma ER/PR negative and HER2 positive with 
extra capsular extension 14/16 lymph nodes positive, date of diagnosis in December 2013. Post operatively, the 
enrollee's PET-CT showed metastatic disease to the bone and pleura and pulmonary nodules, stage IV disease. 
The enrollee received chemotherapy consisting of pertuzumab, trastuzumab, paclitaxel which was discontinued 
after 4 cycles due to neurotoxicity. She was then on monthly zometa and Herceptin until March of 2016. After 
that, PET CT showed negative for any active metastases. The review has determined that the requested PET 
scan is not medically necessary for this enrollee. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan of the entire body.
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 this is medically necessary. The Plan denied your 
request. The Plan says based on the lack of need for skilled therapy, they do not see that Medicare's criteria was 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there is no documentation that you require skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. The records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care or respiratory 
care. There is no documentation that daily skilled services are required. You are walking household distances 
with a two-wheeled walker with contact guard to stand-by assistance, and are stand-by assist for transfers. The 
provided records do not document a significant decline in your functional status to necessitate daily inpatient 
skilled therapy services. The records do not document that services in the home or an assisted living facility 
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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ambrisentan. 
 
You asked the Plan to pre-approve Ambrisentan. You say that you have provided medical records to support 
authorization. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefits. 
 
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 Ambrisentan.  
 
Benefits for Ambrisentan 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic colonoscopy (45378) and EGD diagnostic 
brush wash (43235) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the diagnostic services. You say that it is in the enrollee's best interest to be 
able to have these procedures done with the requested doctor as there is no surgical center near to where the 
enrollee's lives. This being denied is an inconvenience for the enrollee The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 diagnostic colonoscopy (45378) and EGD diagnostic brush wash (43235) to be provided by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is a medical necessity. The 
Plan denied your request. The Plan says according to the information reviewed on appeal, the requested service 
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 the enrollee was admitted on August 16, 2022, after presenting to the emergency 
department (ED) with decreased level of consciousness at the nursing home. The enrollee was unresponsive 
upon arrival to the ED and intubated for airway protection. The enrollee has a stage III sacral ulcer.  On September 4, 2022, a chest tube was inserted for pneumothorax management. On September 20, 2022, 
concern for anoxic encephalopathy enrollee began to follow commands after sedation held. The plan was to 
wean vent as tolerated. On September 22, 2022, per call to the provider, the enrollee is medically stable and 
tolerating trach collar well. There is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving the appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the present acute care hospital. 
 
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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Feraheme (ferumoxytol) injection, for treatment of 
iron deficiency anemia, 1 mg (non-ESRD use) (Q0138). 
 
You asked the Plan to pre-approve the Feraheme injection. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not show 
that the enrollee meets the criteria and the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Feraheme injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records sent show that the enrollee does not currently have iron deficiency 
anemia based on labs submitted from 8/23/22 and has not failed oral supplements. The review has determined 
that the documentation does not support that the Injection, ferumoxytol is medically reasonable for necessary 
for the enrollee. The documentation does not support that the injection, ferumoxytol is safe and effective for the 
enrollee. 
 
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 Feraheme injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Feraheme (ferumoxytol) injection, for treatment of iron deficiency anemia, 1 
mg (non-ESRD use) (Q0138).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office consultation (99245) outpatient office visit 
(99214) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visits. You say that please reconsider the denial. It would be in the 
enrollee's interest to be seen closer to home. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 the office consultation (99245) outpatient office visit (99214) to be provided by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria and this is the best option for their care. The Plan denied your request. The Plan says based on 
Medicare guidelines the long-term acute care hospital services you are requesting do not meet the requirements 
for approval. 
 
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 was admitted with altered mental status in the setting of urosepsis and an 
acute kidney injury. The record indicates that the enrollee has had a complicated hospital course and, although 
is improving, still requires acute care services before transitioning to a lower level of care. The enrollee does 
not require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services.