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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the present setting where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient telehealth provided on July 6, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient telehealth. You say that the services provided to the enrollee were 
medically necessary and the claim should be paid. The Plan denied your request. The Plan says the provider is 
an out-of-network provider and there was no authorization or referral from the enrollee's primary care 
physician. 
 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 telehealth provided on July 6, 2021, 
by an out-of-network (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. You say SNF services are medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, the SNF services you and/or your provider 
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 services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that based on the 
documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a skilled nursing facility is unable to 
provide the level of care the enrollee is currently requiring. The Plan denied your request. The Plan says the 
enrollee's neurologic status is not stable. 
 
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 physician 
reviewer found that the enrollee is being treated for COVID-19 pneumonia. She is suffering from critical 
illness myopathy and delirium. Her hospital course has also been complicated by sepsis, atrial fibrillation, and a 
urinary tract infection. The enrollee is receiving appropriate care at the present acute care hospital. She does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that she requires that are not available at the health care 
setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of 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 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 skilled nursing facility (SNF) services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are other 
in-network providers available to the enrollee. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for imaging services provided by on 
September 10, 2021, and September 13, 2021. 
 
You asked the Plan to waive the copayments for the imaging services. You say that you should not have to pay 
this much for the services provided. The Plan denied your request. The Plan says the proper copayments was 
applied for the services. 
 
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 $85 
copayment for Medicare-covered radiological diagnostic services. The total copayment amount for both dates 
is $170 ($85 copayment + $85 copayment). 
 
  You have been asked to pay a $170 copayment for the imaging services. The imaging services falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 copayments for imaging services provided by on September 10, 2021, and September 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says an authorization request for admission to a skilled nursing facility was approved. 
 
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 there were no acute rehabilitation or nursing needs identified in the record. You are 
medically stable and do not need physician supervision 3 times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. You do not need intensive therapies, consisting of at least three hours of therapy per day, at least five days per week with 
multidisciplinary approach to daily therapy in an IRF. IRF admission is not medically necessary based on lack 
of medical complexity, and lack of acute rehab nursing needs. Needs can be safely met in a lower intensity and 
alternate setting, such as in a SNF. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (81450, G0452) provided on September 
28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for pathology services. You say that in Chapter 3 on pages 3-3 to 3-4 of the Plan's 
2021 Evidence of Coverage (EOC). The Plan denied your request. The Plan says the services were not 
authorized because this provider is a non-network provider who does not work with the member's health plan, 
and the member was referred by a provider who also does not work with the member's plan. The Plan also says 
that the member's primary care physician did not refer for services and the there was no medical necessity for 
an out-of-network provider, such as an urgent or emergency situation that has been documented. The Plan also 
says that alternate in-network providers were found. 
 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 pathology services (81450, G0452) provided on 
September 28, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the freestyle libre test strips (A4253). 
 
You asked the Plan to pre-approve the freestyle libre test strips. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the freestyle libre test strips have not been met. Specifically, there is no indication the requested 
test strips are medically necessary over the preferred. Therefore, we decided that the Plan does not have to pre-
approve the freestyle libre test strips (A4253).
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 is not medically 
necessary. 
 
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical 
condition does not require intensive physician or nursing supervision in an IRF. You may benefit from 
additional physical and occupational therapy, but the documentation does not reveal that this therapy must be 
only on an intensive level 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: 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 you would like the enrollee to stay at the hospital for 
physical therapy since the doctors there have helped her over the last 7 weeks and know of her condition. The 
Plan denied your request. The Plan says this request does not meet the medical necessity criteria for coverage. 
 
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 patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does require physical therapy and occupational therapy services, but the medical records 
provided do not clarify why the patient requires an intensive inpatient rehabilitation therapy program. Our 
physician reviewer also found that there is no documentation that the patient requires the intensive 
rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level appears to be 
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 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 pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that acupuncture is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met in this case. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the documentation demonstrates that the acupuncture 
services will not be performed under the supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, carboplatin, paclitaxel and dexamethasone for 
the enrollee. 
 
You asked the Plan to pre-approve these drugs. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the drug/regimen is not being prescribed for a medically-accepted 
indication. 
 
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 these drugs. Our reviewer says that 
these drugs are not medically reasonable and necessary. Keytruda, carboplatin, paclitaxel and dexamethasone 
are not FDA-approved for the enrollees diagnosis because the patient has had progression of disease on prior 
immunotherapy. The use of these drugs is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these drugs. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda, carboplatin, paclitaxel and dexamethasone for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repair of an abdominal aortic aneurysm. 
 
You asked the Plan to pre-approve the repair of an abdominal aortic aneurysm. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for the requested 
procedure have not been met. 
 
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 repair of an abdominal aortic 
aneurysm. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record indicates that you have a fusiform abdominal 
aortic aneurysm measuring 5.1 cm in largest diameter. The record provided does not establish the presence of a 
factor that would result in a recommendation of repair of an aneurysm less than 5.5 cm at this time. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules of the 
requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
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 the repair of an abdominal aortic aneurysm have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the repair of an abdominal aortic aneurysm.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with an out-of-network gastroenterologist. 
 
You asked the Plan to pre-approve out-of-network office visits. You say that the patient has been under this 
provider's care for reflux disease, irritable bowel syndrome and peptic ulcer disease for 4 years. You say that 
the patient will highly benefit from continuing her care with this physician. The Plan denied your request. The 
Plan says in-network providers are available. 
 
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 
office visits with an out-of-network gastroenterologist.