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 enrollee has ambulatory dysfunction and is a risk 
for falling in his current state. You say that the enrollee needs aggressive therapy. The Plan denied your 
request. The Plan says the enrollee does not meet the guidelines for coverage of IRF care. The Plan says that 
the enrollee can safely receive the services needed in other settings. 
 
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 enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical management of a ruptured appendix and was discharged home on May 5, 
2022, with home health services. There is ongoing weakness. The enrollee's medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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: 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 LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient care at the current hospital and he can safely receive this care in another setting, such as a Skilled 
Nursing Facility (SNF) or at home with home health 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 does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving 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 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) care to be provided by a 
network facility. 
 
 
 You asked the Plan to pre-approve the SNF care. You say that that the enrollee's mobility has declined and is 
considered a fall risk. You say that physical therapy is needed. The Plan denied your request. The Plan says 
authorization denied because the SNF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as home with supervision or an assisted living facility. 
 
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the limited 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the apicoectomy (D3410) and retrograde filling (D3430) 
for teeth #'s 7 and 8, removal of benign oral cyst (D7451), placement of intra-socket biological dressing 
(D7922), and bone replacement grafting (D7953). 
 
You asked the Plan to pre-approve the requested dental services. You say that the services are necessary and 
should be covered. The Plan denied your request. The Plan says you do not meet the age limit requirements for 
the services described by codes D3410 and D3430. The other requested services are not included in your dental 
benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
apicoectomy (D3410) and retrograde filling (D3430) for teeth #'s 7 and 8, removal of benign oral cyst (D7451), 
placement of intra-socket biological dressing (D7922), and bone replacement grafting (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oncologist services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve Oncologist services. You say that you want to continue seeing the same 
provider. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services can be received in-network. 
 
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 
Oncologist services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you still need wound care, you have a feeding tube, 
and need 24-hour care. You say you live with your wife, have dementia, and need to get stronger. The Plan 
denied your request. The Plan says that authorization denied because the SNF care is not medically necessary 
and your needs can be met at a lower level of care such as home with home health, in residential care, or home 
with close follow-up with their doctor. 
 
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 the 
SNF care is medically necessary. Our physician reviewer found based on the documentation provided, qualify 
for SNF coverage. You do have documented skilled nursing needs in the form of enteral feeding and 
gallbladder tube monitoring. You do not have documented skilled therapy needs, though intermittent therapy is 
reasonable. Daily skilled services are required to establish a maintenance program or to prevent deterioration of 
your 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 care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visits (99213) repair of complex retinal 
detachment with vitrectomy and membrane peeling (67113) provided on June 4, 2021 to October 26, 2021 by 
an out-of-network (OON) provider while outside of the United States. 
 
You asked the Plan to pay for the unlisted services. You say that during travel in Costa Rica, you suffered a 
detached retina in your left eye. This required emergency surgery pm September 29, 2021. Unfortunately, the 
detachment recurred in the same eye required another emergency surgery on October 22, 2021. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient office 
visits (99213) repair of complex retinal detachment with vitrectomy and membrane peeling (67113) provided 
on June 4, 2021 to October 26, 2021 by an out-of-network (OON) provider while outside of the United States.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Neupogen. 
 
You asked the Plan to pre-approve Neupogen. You say that the enrollee is highly susceptible to infection. The 
Plan denied your request. The Plan says that the enrollee is not at significant risk of febrile neutropenia. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Neupogen. Our physician reviewer 
found that the enrollee has drug-induced neutropenia resulting from the treatment of cytomegalovirus (CMV) 
viremia treated with Valcyte. Treatment of drug-induced agranulocytosis with granulocyte colony-stimulating 
factor (G-CSF) is generally associated with shorter recovery times, less antibiotic use, and shorter length of 
hospitalization compared with historic or concurrent controls, based on small uncontrolled studies. Although 
their efficacy is not conclusively proven, growth factors have minimal toxicity in this setting. The service is 
reasonable and medically necessary and likely to be safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neupogen have been met. Therefore, we decided that the Plan has to pre-
approve Neupogen.  
 
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 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 at the current functional level, you do not need 3 hours a day five days a week of IRF 
therapies with interdisciplinary management and you will not tolerate IRF level of intensity. While you may 
benefit from physical therapy, and occupational therapy, your rehab needs can be addressed at a low intensity 
alternate setting such as in-home with therapies. 
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs admission to an 
LTACH for continued respiratory weaning, therapy and complex medical management. You say that the 
enrollee clearly meets the criteria and care can be managed at LTACH level of care. The Plan denied your 
request. The Plan says care can safely be received in another 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 receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically reasonable and 
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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the record 
indicates that the enrollee has age related osteoporosis without osteoporotic fracture. The requested medication 
is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred 
step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an 
adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not 
satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy provided on December 3, 
2021. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you received a letter from the plan 
stating the procedure you had done would be fully covered. The Plan denied your request. The Plan says you 
have been charged the correct copayment amount. 
 
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 an in-
network $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient 
hospital.  
 You have been asked to pay a $295 copayment for the endoscopy. The endoscopy falls within the Outpatient 
Surgery and Other Medical 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 copayment for the endoscopy provided on 
December 3, 2021.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the enrollee does not have documented skilled 
nursing needs or documented skilled 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, as a 
practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration with 
periradicular surgery (D3431). 
 
You asked the Plan to pre-approve the dental service. You say that you need this service in coordination with 
an approved root canal. The Plan denied your request. The Plan says biologic materials to aid in tissue 
regeneration with periradicular surgery is not listed as a covered service. 
 
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, the requested biologic materials to aid 
in tissue regeneration with periradicular surgery is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration with 
periradicular surgery (D3431).