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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested admission to 
an IRF. 
 
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 
enrollee does not meet criteria for the requested admission to an IRF. 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 
encephalopathy, renal failure, myocardial infarction, atrial fibrillation, and gastrointestinal bleeding. 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, in an intensive rehabilitation therapy program. While the enrollee has 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for IV therapy provided on November 9, 
2021. 
 
You asked the Plan to waive the coinsurance for IV therapy. You say that for over the last year and a half you 
have been receiving IV therapy services and the coinsurance has always been $36.87 or 39.79. The Plan denied 
your request. The Plan says the coinsurance was applied correctly. The claim was billed for additional 
injections you received in addition to the IV therapy, which resulted in a higher allowed amount. The increased 
allowed amount increased the coinsurance.  
 
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 other Part B covered drugs for your IV therapy.  
 
 
  You have been asked to pay $143 for IV therapy. IV therapy 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 the coinsurance for IV therapy provided on 
November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 6, 2021, to 
December 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically reasonable and 
necessary as ordered by the patient's treating nephrologist. The Plan denied your request. The Plan says the 
rendering provider is a non-participating provider, and they did not authorize any services for this provider. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 laboratory services provided on December 6, 
2021, to December 15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services provided on January 10, 2022, 
by an OON provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that you are an in-network provider with 
the Plan and a referral from the enrollee's primary care provider (PCP) should not be needed. The Plan denied 
your request. The Plan says the rendering provider is an OON provider, and it was confirmed with the 
enrollee's PCP that they did not refer them there was also no approved authorization. Also, the service rendered 
was not urgent or emergent. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 ophthalmological services provided on January 
10, 2022, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not meet 
the CMS criteria for skilled nursing 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 services. Our reviewer says that 
you do not qualify for SNF coverage. Our physician reviewer found that you do not have documented skilled 
nursing needs or skilled therapy needs. Your care needs 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need PM&R physician close supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. While the enrollee may benefit from physical therapy, and occupational therapy, her rehab 
needs can be addressed at a low intensity alternate setting such as in a skilled nursing facility with therapies as 
needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not need 3 hours a day five days a week of IRF therapies with 
interdisciplinary management. The complexity of the enrollee's nursing, medical and rehabilitation needs do 
not require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care. 
While the enrollee may benefit from physical therapy, and occupational therapy, her rehab needs can be 
addressed at a low intensity alternate setting such as 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are unable to drive 
due to a medical diagnosis and broken bones. You also say you can no longer afford Uber rides. The Plan 
denied your request. The Plan says you have used 13 of the allotted 12 one-way trips approved. The Plan also 
says that additional trips are not covered by the Plan. 
 
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 12 one-way trips per year 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 ten (10) additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and related accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options and related 
accessories. You say that a group 3 power wheelchair with multiple power options is not medically reasonable 
and necessary. The Plan denied your request. The Plan says the criteria for coverage of the requested power 
wheelchair have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power 
options is subject to the criteria listed 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 a group 3 power wheelchair with 
multiple power options and related accessories. Our reviewer says that the criteria for a group 3 power 
wheelchair with multiple power options have not been met. Our physician reviewer found the enrollee is a 71-
year-old female with a history of multiple sclerosis. Based on the medical records provided there is no 
documentation that the enrollee satisfies the listed coverage criteria for the group 3 power wheelchair with 
multiple power options. The enrollee is not high risk for skin breakdown and does not utilize intermittent 
catheterization for bladder management or have documented muscle spasticity. AS the enrollee does not meet 
criteria for both power tilt and power recline, the request for group 3 power wheelchair with multiple power 
options does not meet Medicare criteria for reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 power wheelchair with multiple power options and related accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair with multiple power options and related accessories.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says that this drug is not covered under the enrollee's 
medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 
reasonable and necessary.  
 
In this case, the Plan originally denied coverage based on Medicare rules for how the drug will be 
administered. However, confirmation regarding how it was to be administered was not in the case file. We 
requested additional information and confirmed the drug was to be administered under physician supervision 
and included in the physicians bill. 
 
Therefore, 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 Botox. Our reviewer says that 
the requested drug is medically reasonable and necessary. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of chronic migraine headaches at least 15 days per month with headache 
lasting 4 hours a day or longer. The Food and Drug Administration has stated that the requested drug is 
indicated for the enrollee's condition. The elements of the coverage criteria are satisfied.  The requested service 
is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have been met. Therefore, we decided that the Plan has to pre-approve 
Botox.  
 
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 an outpatient office visit provided on January 11, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you would like a retro authorization and 
for the claim to be reprocessed for payment. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 an outpatient office visit provided on January 11, 
2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (CPT code(s): J9271), Carboplatin (J9045), 
Dexamethasone (J8540), and Paclitaxel (J9264). 
 
You asked the Plan to pre-approve the medication. You say that the requested regimen is for treatment of non-
small cell lung cancer (NSCLC) after previous treatment is not supported by NCCN guidelines. The Plan 
denied your request. The Plan says the use of these medicines together is not approved for the enrollee's 
condition after previous treatment. The Plan states the enrollee's doctor has requested a combination treatment 
and the doctor's notes do not show why the enrollee cannot take a single medicine (single -agent immune 
checkpoint inhibitors or chemotherapy). 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the regimen of Keytruda, Carboplatin, Dexamethasone, and Paclitaxel is not FDA-approved for the 
enrollee's diagnosis. The use of Keytruda, Carboplatin, Dexamethasone, and Paclitaxel is not supported by one 
of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The documentation does not support that the regimen of Keytruda, Carboplatin, Dexamethasone, and Paclitaxel is 
safe and effective and otherwise reasonable and necessary for the enrollee 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (CPT code(s): J9271), Carboplatin (J9045), Dexamethasone (J8540), and 
Paclitaxel (J9264).
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 need LTACH care. The Plan denied 
your request. The Plan says you do not meet criteria for an LTACH admission. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care facility. The health plan has approved ongoing care in the current acute care facility. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and 
able to be furnished 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: 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 admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a urinary tract 
infection (UTI) and sepsis. From a nursing perspective, the enrollee received enteral nutrition and oral 
medications and insulin. The enrollee had stable vital signs. She had chronic foley catheter care and wound 
care to her sacrum and wound vac to her G-tube site. Regarding rehabilitation services, the enrollee required a 
mechanical lift for transfers and assist with activities of daily living. 
 
There are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).