Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the services you received on February 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the provider needs 
to bill Medicaid. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the services by a contract provider. The file does not show that the Plan provided notice 
that the services would not be covered. Under Medicare rules, this means the services is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for the services you received on February 24, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not require daily skilled nursing or therapy services. 
 
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 physician reviewer 
found that the enrollee does not have documented skilled nursing or skilled therapy needs. The enrollee is not 
sown to have an acute decline in function. Daily skilled services are not 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 skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to return to being independent. The Plan 
denied your request. The Plan says that the medical records do not support the ability to tolerate 3 hours of 
therapy a day. 
 
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 physician reviewer found 
that you were hospitalized with congestive heart failure decompensation. The clinical documentation shows 
that you have active comorbidities that would benefit from close medical supervision in an inpatient setting that 
focuses on rehabilitation. The documentation shows that you would tolerate 3 hours of therapy per day, 5 days 
per week. Therefore, you would benefit from 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 has to pre-
approve acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: 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 physical therapy, more dialysis 
and long-term care. The Plan denied your request. The Plan says you are receiving appropriate in-patient acute 
care and are currently unstable for transfer to an LTACH. 
 
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 you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. there are no services available at the LTACH that you require that are not available at the health 
care setting being offered by the Plan. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery on December 16, 2021, 
to December 20, 2021. 
 
You asked the Plan to waive the coinsurance for surgery. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost-sharing you are being charged is correct. 
 
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 20% 
coinsurance for surgery performed at an outpatient hospital facility. The provider billed in the amount of 
$4,170.25 and there is a 20% coinsurance. $4,170.25 x 20% coinsurance = $834.05. Therefore, the total cost-
sharing amount is $834.05. 
 
 
 
 
 You have been asked to pay a 20% coinsurance for surgery. Surgery falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 outpatient surgery on December 16, 2021, to December 20, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery of both eyes to be provided by an out-
of-service area (OOSA) provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says outside of the Plans Service Area (Florida) the Plan covers only 
medical conditions that require urgent or emergent care, there is no physicians order for the cataract surgery, 
and your eye care must be coordinated by the assigned Primary Ophthalmology Doctor (POD) in the county 
where you reside.  
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 
cataract surgery of both eyes to be provided by an out-of-service area (OOSA) provider.
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 they are trying to get the enrollee back in inpatient 
rehabilitation The Plan denied your request. The Plan says authorization denied because the IRF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
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 require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of care (ex. 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 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 inpatient psychiatric treatment from July 10 forward. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment from July 10 forward. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment from 
July 10 forward. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
based upon review of the records provided for the admission of this enrollee does not meet the criteria for July 10, 2022 forward as this enrollee was not shown to be a danger to herself or others. There were no delusions, 
auditory or visual hallucinations noted. She was cooperative/compliant with treatment while not showing any 
threats the safety as an enrollee awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment from July 10 forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment from July 10 
forward.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs medication management. The 
Plan denied your request. The Plan says the enrollee does not require daily skilled services on an inpatient 
basis. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer 
found that the enrollee does not have documented skilled nursing or therapy needs. Daily skilled services are 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs are custodial. 
 
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 skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that this drug is medically necessary. 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 Euflexxa. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of drugs Orthovisc or Supartz FX before they will approve the requested drug, Euflexxa. In this case, there 
is no indication that the patient has tried and failed the required drugs. Based on the medical records provided 
and the Medicare-approved major drug compendia there is no indication that the plan's required drug(s) would 
likely be less effective and/or likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ESI (CPT code 62323). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has been getting injections for years 
and they are medically necessary. The Plan denied your request. The Plan says the enrollee's request is not 
medically necessary because the enrollee's records show they do not have documentation that the prior 
injection provided sustained improvement for 3 months or that this will be a different approach or medication. 
 
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 injection. Our physician reviewer 
found the request is not medically necessary because the records do not document that the prior injection 
provided sustained improvement for 3 months or that this will be a different approach or medication. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the ESI (CPT code 62323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee joint replacement surgery to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve knee joint replacement surgery to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
knee joint replacement surgery to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in dire need of physical therapy and the 
skilled nursing facility will not be sufficient to your needs. The Plan denied your request. The Plan says you do 
not meet IRF criteria, is not medically necessary, and a lower of level of care might be appropriate. Skilled 
nursing facility level of care was offered. 
 
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 you may benefit from continued physical and occupational therapy. Your rehabilitation needs can be safely provided in a lower intensity and alternate setting such as in a skilled nursing facility. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950 x7) and crowns (D2750 x7). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was approved for the allowed benefit of 3 core buildups 
and 3 crowns, therefore any additional request for the same service will be denied as the benefit will be 
exhausted once those approved services are performed. Therefore, we decided that the Plan does not have to 
pre-approve core buildup (D2950 x7) and crowns (D2750 x7).
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 have complex medical or intensive rehabilitation needs. He has 
no acute neurological injury, no contractures, muscle spasms or autonomic instability. He is cognitively 
impaired, easily distractable and requires repeat cuing. He is not able to tolerate or benefit from intensive 
rehabilitation due to his cognitive status and does not require frequent oversight from a psychiatrist as his 
rehabilitation needs are routine post-op 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 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 the HH PT visits (CPT code G0151 x9). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says they previously approved visits to teach you and any caregivers a home exercise 
program. The Plan state your records suggest that continuing this exercise program should help you maintain 
your level of function or improve further. The Plan states they do not show that additional home therapy visits 
are needed for this to occur, and your records do not support the need for a skilled physical therapist to make 
more home visits at this time. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found you do not have documented skilled PT needs.  You live in a supervised setting with available caregivers 
24/7. As such, the request for ongoing HH PT services is not medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the HH PT visits (CPT code G0151 x9).