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 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 there is no need for physician supervision 3 times per week (at a minimum) for 
the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to 
daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of 
therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no 
documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and 
occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal home helper services.
You asked the Plan to pre-approve the personal home helper services. You say that you do have at least two ADL's, including a pacemaker and high blood pressure, which qualify you to receive this benefit. The Plan denied your request. The Plan says your health care provider did not confirm that you need assistance with at least two ADL's, which is necessary for you to receive this benefit according to the criteria noted in your 2021 Evidence of Coverage (EOC).
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 personal home helper services. Our reviewer says that the personal home helper services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that you meet the criteria for coverage, specifically, the records do not support that you require assistance with at least 2 activities of daily living (ADL's). Our reviewer found that an office visit note of December 6, 2021 specifically states that you are independent with bathing, dressing, toileting, transferring, continence and feeding. Records also state you are independent with phone operation, shopping, food preparation, medication management, travel and finances. Our physician reviewer also found that you are reported to do your laundry completely and to maintain your housekeeping alone or with occasional assistance. 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 personal home helper services have not been met. Therefore, we decided that the Plan does not have to pre-approve personal home helper 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 the LTACH service is medically 
necessary. The Plan denied your request. The Plan says LTACH is not medically necessary, and the enrollee's 
needs can be met at a lower level of care such as a SNF. 
 
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 is improving but requires ongoing acute care services. The medical 
record does not indicate that the enrollee requires services that he is not currently receiving but that would be 
available at the LTACH 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 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 the extraspinal chiropractic manipulative treatment (98943) 
and additional supplies (99072) provided on August 31, 2021. 
 
You asked the Plan to pay for the extraspinal chiropractic manipulative treatment and additional supplies.. You 
say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says the services at issue do not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Additionally, CPT code 
99072 has a status indicator of B. This means that the payment for CPT code 99072 is always bundled into the 
payment for another procedure or service. Therefore, we decided that the Plan does not have to pay for the 
extraspinal chiropractic manipulative treatment (98943) and additional supplies (99072) provided on August 
31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan (J9312). 
 
You asked the Plan to pre-approve Rituxan. You say that this drug is medically necessary for your condition. 
The Plan denied your request. The Plan says step therapy criteria have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Rituxan. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that you are a 70-year-
old female with rheumatoid arthritis. The Plan requires a trial of Remicade, Inflectra or Simponi Aria before 
they will approve the requested drug, Rituxan. Based on the medical records provided, you have not tried and 
failed the required drugs. In addition, there is no indication that the Plans required drugs would likely be less 
effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan (J9312).
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 the enrollee requires skilled nursing services. The
Plan denied your request. The Plan says the criteria for admission to an SNF are not met. The enrollee does not
require skilled therapy services as there is no expectation of functional improvement in a reasonable time
period. In addition, the self-care tasks the enrollee requires may be provided by unskilled persons and do not
require the hands-on assistance of a licensed practitioner.
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 daily
skilled services are not necessary. Our physician reviewer found that based on the medical records provided,
there is no documentation that the enrollee requires skilled nursing services which require the specialized skill,
knowledge and judgment of a skilled professional nurse in order to safely and effectively provide medically
necessary and reasonable treatment. Records do not document the need for intravenous medications or complex
wound care. The enrollee does require skilled therapy services, however medical records do not support that
daily skilled services are required. The enrollee is not functionally different from his pre-admission level of
dependence for mobility, transfers and activities of daily living. As a practical matter, the enrollee does not
require the services on an inpatient basis, only in a skilled nursing facility. Services in a long-term care facility
on a part time basis appear 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: 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 intensive therapies, consisting of at least 3 hours of
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee
may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be safely met in an
alternate and lower intensity 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: 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) 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 LTC 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 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 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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician 
evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bed and floor alarms.
You asked the Plan to pre-approve the bed and floor alarms. You say that you would like reconsideration because the member is not aware of their limitations and the alarms will prevent further injury. The Plan denied your request. The Plan says these alarms are not strictly medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve bed and floor alarms.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. You say that you have an acoustic neuroma on left side of your brain and had radiation, which caused hearing loss in left ear. You say that you had a doctor visit last month and had a hearing test and your left ear needed a hearing aid as well as your right ear to improve hearing. The Plan denied your request. The Plan says you have met your benefit maximum with hearing aids received on December 30, 2021.
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 plan's coverage rules apply in this case. The Plan pays for hearing aids only with one hearing aid(s) every 3 years.
We looked at the file and the Plan's rules. The file shows that you have met your benefit maximum with hearing aids received on December 30, 2021. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (L1845). 
 
You asked the Plan to pre-approve the knee orthosis. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis with adjustable knee joints (L1832, 
L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial- lateral and 
rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a 
surgical procedure on the knee(s) or when knee instability is documented by examination of the beneficiary and 
objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). 
 
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 knee orthosis. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the records do not document that the 
enrollee has had a recent injury to or a surgical procedure on the knee(s) or that he has knee instability 
documented by examination with objective description of joint laxity. 
 
 
 
 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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the knee orthosis (L1845).
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical 
therapy, and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the proton treatment delivery; simple, with 
compensation (CPT code 77522). 
 
You asked the Plan to pre-approve the proton treatment delivery. You say that proton beam therapy is a 
covered service under traditional Medicare for this diagnosis. The Plan denied your request. The Plan says a 
review of the literature indicates that proton-beam radiotherapy (PBRT) is not the standard of care for prostate 
cancer and proton beam therapy for treatment of prostate cancer should only be performed within the context of 
a prospective clinical trial. 
 
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 proton treatment delivery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found proton therapy would arguably exceed need for you and proton therapy 
may or may not be better than IMRT/IGRT. 
 
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 proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the proton treatment delivery; simple, with compensation (CPT code 77522).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor supplies. 
 
You asked the Plan to pre-approve the requested services. You say that you are in need of the supplies. The 
Plan denied your request. The Plan says the items are non-covered under the durable medical equipment 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that the requested supplies are not covered when billed with codes 
A9276 and A9277. Based on this information, we decided that Medicare rules for coverage of the requested 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous 
glucose monitor supplies.