Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323) and the associated arthrocentesis 
(20610). 
 
You asked the Plan to pre-approve Euflexxa and the associated arthrocentesis. You say that the enrollee has 
undergone treatment with Synvisc One on November 11, 2021, which was ineffective after the last injection, 
the enrollee had no pain relief. You also say that the use of Euflexxa is supported to treat the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee had no significant improvement in pain and 
functional capacity achieved with prior series of viscosupplementation. The Plan also says that the provider 
states that enrollee did not have any significant reduction in the doses of non-steroidal anti-inflammatory drug 
(NSAID) medications taken or reduction in the number of intra-articular steroid injections to the knees during 
the six-month period following the injection. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat series* of hyaluronan knee injection(s) for 
patients who have responded to a prior series is considered to be reasonable and necessary when there is 
significant reduction in the doses of non-steroidal anti-inflammatory drug (NSAID) medications taken or 
reduction in the number of intra-articular steroid injections to the knees during the six-month period following 
the injection(s). 
 
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 and the associated 
arthrocentesis. Our reviewer says that Euflexxa is not reasonable or medically necessary for this enrollee. Our 
physician reviewer found the enrollee did not have any significant reduction in the doses of NSAID 
medications taken or reduction in the number of intra-articular steroid injections to the knees during the six-
month period following the injection. 
 
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 and the associated arthrocentesis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Euflexxa (J7323) and the associated arthrocentesis (20610).
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 not safe to be at home due to issues with 
balance and fall risk. The Plan denied your request. The Plan says based on Medicare guidelines, your request 
for approval of an IRF admission does 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 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. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer for Skilled Nursing Facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF transfer. You say that you would like reconsideration because the 
enrollee is not receiving adequate care at their current SNF. The Plan denied your request. The Plan says there 
is no documentation that the present facility is unable to provide the rehabilitation services that are needed for 
the enrollee. 
 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 transfer. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there are no services offered at a 
different SNF that are not offered at the current SNF.  Admission to a different SNF for inpatient skilled rehab 
services 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 the SNF transfer have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a transfer for Skilled Nursing Facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brow ptosis repair for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there was no documentation supporting functional impairment (visual field 
obstruction) supported with a difference of 12 degrees or more or 30% superior visual field difference. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the case file does not contain documentation that demonstrates that the enrollee has visual 
field obstruction with a difference of 12 degrees or more or 30% superior visual field difference, as stipulated 
in LCD L34528. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve brow ptosis repair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Oncology (urothelial), mRNA, gene expression profiling 
(0013M) rendered by the out-of-network (OON) provider on November 3, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal.  The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for 
this service. Therefore, we decided that the Plan does not have to pay for the Oncology (urothelial), mRNA, 
gene expression profiling (0013M) rendered by the out-of-network (OON) provider on November 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 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 services. Our reviewer says that the 
requested continuation of services is not medically reasonable or necessary Our physician reviewer found there 
are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that 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 the 
service is medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs, though monitoring of your surgical incision, respiratory status and cognitive status are reasonable.  You 
do have documented skilled therapy needs. The documentation does not yet establish that you are at your 
baseline or have reached a new baseline of function. Daily skilled services are required to establish a 
maintenance program and/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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need 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.  
 You are medically stable and do not need physical medicine and rehabilitation physician close supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no rehab nursing needs identified or documented in the record. At baseline you 
needed assist and hence, you need routine physical and occupational therapy and that can be safely provided in 
a skilled nursing facility and do not need IRF level of therapies. You needed assist even prior to admission and 
will not be able to make significant functional progress in 7 -10 days as predicted in an IRF. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide visits. 
 
You asked the Plan to pre-approve home health aide visits. You say that the requested home health aide visits 
are medically necessary. The Plan denied your request. The Plan says the requested home health aide visits are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide visits. Our reviewer 
says that the requested home health aide visits are not medically necessary. Our physician reviewer found 
based on the documentation provided, the enrollee does not have documented skilled needs. The enrollees 
needs appear to be custodial.  Home health aide (HHA) services are not medically necessary or reasonable to 
aide in the treatment of an acute illness or injury. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health aide visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with hypoxia. From a 
nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs.   His lungs were 
clear. Regarding rehabilitation services, the enrollee received physical therapy.  The enrollee was at an 
independent to contact guard assist level for functional mobility including gait to 350 feet. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 
1, 2021, to July 13, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were under the 
impression that all the bills for your medical care starting in June 2021 were covered and you believe this 
service should be as well. The Plan denied your request. The Plan says the copayment amount 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 $200 
copayment for each day for days 1 to 5 for Medicare-covered inpatient hospital care.  
  You have been asked to pay a $1,000 copayment for inpatient hospital care ($200/day x 5 days = $1,000).  
The inpatient hospital care services fall within the Inpatient Hospital Care 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 inpatient hospital care provided from July 1, 2021, to July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554) supply allowance used with a therapeutic CGM device (K0553). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor and supply allowance. You say 
that say the medical records provided support the necessity of the services in dispute. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria as they do not inject insulin 3 or more 
times per day or use an insulin pump and need to make changes to insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor and 
supply allowance have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (K0554) supply 
allowance used with a therapeutic CGM device (K0553).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a licensed practical 
nurse (LPN) (G0300). 
 
You asked the Plan to pre-approve direct skilled nursing services of a LPN. You say that you disagree with the 
Plan's decision, and would like the denied authorization to be reconsidered. The Plan denied your request. The 
Plan says the documentation submitted indicates this request for home health is custodial in nature and does not 
support medical necessity. 
 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 direct skilled nursing services of a LPN. 
Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer 
found the documentation doesnt support that the member requires additional skilled nursing services to 
provide treatment that is medically necessary. Our reviewer found that the member does not require additional 
skilled nursing services to effectively provide treatment, care, and/or services in order to improve the members 
condition, perform a maintenance program to maintain the members condition and/or prevent deterioration. 
Our physician reviewer also found that the member has been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of direct skilled nursing services of a LPN have not been met. Therefore, we 
decided that the Plan does not have to pre-approve direct skilled nursing services of a licensed practical nurse 
(LPN) (G0300).