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

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for inpatient 
surgery. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 referral to an out-of-network provider for inpatient surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of inpatient 
rehabilitation admission. The Plan denied your request. The Plan says we denied IRF admission because the 
record shows that you do not meet Medicare guidelines or services in an inpatient rehabilitation facility. 
 
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 you were admitted for weakness and anemia. Medical problems are stable. There are 
no complex nursing or rehabilitation needs.  While you have a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the admission to an inpatient rehabilitation facility is 
needed for the enrollee. The Plan denied your request. The Plan says based on Medicare guidelines the 
inpatient rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for osteomyelitis and below the knee amputation. Medical 
problems are stable.  There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: 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 need these services to regain strength and be 
able to move with more independence. The Plan denied your request. The Plan says the criteria for admission 
to an IRF are not met in this case. The services you need can be safely provided in an alternate 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says ventilators used to 
provide bi-level PAP therapy are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found that you have a diagnosis of COPD, but pulmonary function tests indicate severe restrictive lung disease.  
An element of obstruction cannot be ruled out. An arterial blood gas (ABG) test done under unknown 
circumstances showed severe hypoxemia with mild elevation of PaCO2 (partial pressure of carbon dioxide) 
related to metabolic alkalosis. The hypoxemia suggests you were acutely ill at the time. There is no 
documentation of chronic carbon dioxide (CO2) retention.  There is no diagnosis of neuromuscular disease or thoracic restrictive disease. If there is chronic CO2 retention, 
you may benefit from BiPAP during sleep. However, Medicare does not cover a home ventilator when used as 
BiPAP. Therefore, a home ventilator is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER visit provided on November 21, 2021. 
 
You asked the Plan to pay for the ER visit. The Plan denied your request. The Plan says the member was 
enrolled in hospice at the time of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ER visit provided on November 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid receiver replacement provided on May 2, 
2022. 
 
You asked the Plan to pay for the hearing aid receiver replacement. You say that you would like this service to 
be reconsidered for coverage. The Plan denied your request. The Plan says repairs and replacement parts are 
not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan contract says 
that hearing magnifiers or amplifiers, personal sound boosters, sound amplifiers, previously purchased hearing 
aids, warranty or service costs for hearing aid maintenance, replacement batteries, and recharging equipment 
are excluded from coverage.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid receiver replacement have not been met. Therefore, we decided that the Plan does 
not have to pay for the hearing aid receiver replacement provided on May 2, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on December 4, 2021. 
 
You asked the Plan to pay for the subsequent hospital care. The Plan denied your request. The Plan says 
original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital care provided on December 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tradjenta. 
 
You asked the Plan to pre-approve Tradjenta. You say that the enrollee requires the medication for his diabetes 
control. The Plan denied your request. The Plan says this medication does not meet the criteria to be covered 
under the Part B benefit. 
 
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 Tradjenta.  
 
 Benefits for Tradjenta 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: 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 enrollee is currently stable for 
transfer and requires long-term acute care in an LTACH. The Plan denied your request. The Plan says the 
criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current 
acute setting, and the LTACH would provide no additional services. 
 
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 the enrollee was admitted to the acute care hospital with peritoneal abscess, sepsis, dehydration requiring 
intubation, BiPAP (bilevel positive airway pressure), oxygen support, intravenous antibiotics, Fistula takedown 
and placement of Malecot drains, fistula management, and total parenteral nutrition (TPN). Recent notes 
describe the enrollee as having been extubated undergoing weaning trials but still on TPN. The enrollee 
appears to be improving but is still somewhat unstable without a more permanent feeding source. Only 
additional short-term acute care services are required can safely be administered at the current facility until the 
enrollee is more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, transfer to the LTACH is 
not medically necessary as the enrollee is not yet stable for transfer and as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you prefer to admit to acute rehabilitation because 
you were independent before your hospitalization and want to return to being independent. The Plan denied 
your request. The Plan says admission to acute inpatient rehabilitation was denied as not meeting criteria, and it 
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 you do not have complex or specialized rehabilitation needs and do not require 
intensive rehabilitation. You are walking 150 feet, which is above a home care level of function. You do not 
require frequent physiatry oversight or rehabilitation nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on February 27, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this 
service was provided by certified paramedics, and is a medical service. The Plan denied your request. The Plan 
says it was confirmed with the provider that you refused transportation, and this claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 27, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on February 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on October 29, 2021. 
 
You asked the Plan to pay for the testing services. You say that the results aid in the identification of prostate 
cancer. The Plan denied your request. The Plan says the documentation does not support the testing on the 
billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. In this case, there are insufficient medical records from the treating 
provided to determine whether the rules for coverage have been met. Therefore, we decided that the Plan does 
not have to pay for the gene panel testing provided on October 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan drops. 
 
You asked the Plan to pre-approve Rocklatan drops. You say that the enrollee requires continuation of the 
current treatment in order to prevent any further optic nerve damage, resulting in permanent vision loss. The 
Plan denied your request. The Plan says Rocklatan is a self-administered drug, and does not fall under Part B 
coverage. 
 
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 Rocklatan drops.  
 
Benefits for Rocklatan drops 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Incobotulinumtoxin (Xeomin). 
 
You asked the Plan to pre-approve Xeomin. The Plan denied your request. The Plan says this request was 
denied because the records show the drug will be supplied by a pharmacy. 
 
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. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Incobotulinumtoxin (Xeomin).  
 
Benefits for Xeomin 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: 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 has completed the acute care 
hospital (ACH) stay and is ready for LTACH level of care. The Plan denied your request. The Plan says the 
enrollee does not require extensive or complex wound care management by skilled nursing of at least 6.5 hours 
per day. Additionally, the wound care does not require daily intervention by a physician. The clinical 
assessment does not support the expectation of a stay to be at least 25 days. Criteria for admission to the 
LTACH has not been met. The enrollee's medical needs are being met in the current acute setting. 
 
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 the enrollee is currently undergoing treatment at an ACH following surgery for a 
pelvic mass. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services 
that are not currently available. As an LTACH and an ACH are licensed to provide the same level of care, there 
is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can 
then be transferred/discharged to a lower level of care for any ongoing long-term care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation procedure 
(64624) and the use of sedation (01992). 
 
You asked the Plan to pre-approve a radiofrequency ablation procedure. You say that the requested procedure 
is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of a 
genicular nerve radiofrequency ablation in the setting of left knee osteoarthritis have not been demonstrated in 
the peer-reviewed literature. 
 
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 radiofrequency ablation procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered experimental/ investigational and its role in the 
treatment of osteoarthritis is still being considered. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation procedure (64624) and the 
use of sedation (01992).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 10, 
2022. 
 
You asked the Plan to pay for the rest home visit. The Plan denied your request. The Plan says original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 10, 
2022.