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 you have been admitted to the hospital 3 times
within a month. You say that you need IRF care for conditioning. The Plan denied your request. The Plan says
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 shortness of breath and respiratory failure requiring bi-level positive airway pressure
(BIPAP.) 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 acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires multiple therapies and has
sufficient medical complexity to be best treated in an IRF. A lower level of care would place the enrollee at risk
for a higher rate of complications and rehospitalization. The Plan denied your request. The Plan says the
criteria for admission to an IRF are not met. The necessary services can be provided in an alternate setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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 acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary for this
enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The
enrollee does not require the intensity of services provided in an IRF.
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 the enrollee's nursing, medical and rehabilitation needs
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While
the documentation does support a need for physical and/or occupational therapy, there is no documented need
for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this
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 acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a
right total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request.
The Plan says there is no documentation provided to support the expectation the enrollee will require a greater
than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found the enrollee is approved for a right total shoulder arthroplasty. The record
does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or
more midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

You asked the Plan to pre-approve additional PT. You say that the denial of additional therapy will most
certainly cause a rapid decline in the enrollee's ability to function and participate in the community. The Plan
denied your request. The Plan says the requested additional physical therapy visits are not medically necessary.
The requested treatment is repetitive and able to be completed as home exercises. Unique input from a skilled
therapist is not required for the requested care.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
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 additional PT. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found that the enrollee has had no change in her medical condition to
warrant therapeutic efforts with physical therapy. The visits are too excessive for the enrollee's condition.
Documentation does not support that the unique skills of a professional therapist are required to provide
treatment safely and effectively, or that the services can only be safely and effectively performed by a therapist
or under the supervision of a therapist. The request for additional physical therapy is not medically necessary 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 additional PT have not been met. Therefore, we decided that the Plan does not
have to pre-approve ten (10) additional physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durvalumab (J9173).
You asked the Plan to pre-approve durvalumab. You say that durvalumab is medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 durvalumab. Our reviewer says that
durvalumab is not medically necessary. Our physician reviewer found durvalumab is approvable for stage III
non-small cell lung cancer after chemotherapy or radiation with response. The record shows this enrollee has
brain metastasis and therefore criteria is not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of durvalumab have not been met. Therefore, we decided that the Plan does not
have to pre-approve durvalumab (J9173).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an additional eyeglass frame (V2020), bifocal lens
(V2200), lens tint (V2744) and anti-reflective coating (V2750) provided on June 17, 2021 by an in-network
provider.
You asked the Plan to reimburse you for an additional eyeglass frame, bifocal lens, lens tint and anti-reflective
coating. You say that you are requesting reimbursement for the amount you paid for your eyeglasses. The Plan
denied your request. The Plan says there is no further vision benefit available for the purchase of your second
pair of lenses and anti-reflective coating because you have already utilized your full benefit on the first pair of
eyeglasses.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan pays up to $170 every year for non-Medicare covered eyewear. The Plan also says you are
responsible for any amount above the eyewear coverage limit.
We looked at the file and the Plan's rules. The records show that your first pair of eyeglasses including the anti-
reflective coating, bifocal lenses and lens tint was paid by the Plan. You received your total allowed amount of
$170 for your eyewear. The records also show that the reimbursement you are requesting is for a second set of
eyeglasses. There is no further vision benefit amount available for the second pair of eyeglasses. The EOC
confirms that you are responsible for any amount above the eyewear coverage limit. Based on this information,
we decided that the Plan's rules for coverage of eyeglass frames, bifocal lenses, lens tint and anti-reflective
coating have not been met. Therefore, we decided that the Plan does not have to reimburse you for an
additional eyeglass frame (V2020), bifocal lens (V2200), lens tint (V2744) and anti-reflective coating (V2750)
provided on June 17, 2021 by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0480, 80307) rendered by the
out-of-network (OON) provider on March 23, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the drug testing services (G0480, 80307) rendered by the out-of-network (OON)
provider on March 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection without imaging services
(62322).
You asked the Plan to pre-approve an epidural steroid injection without imaging services. You say that these
services are medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for
coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that except for unique circumstances, epidural steroid
injections must be performed through an imaging service.
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 an epidural steroid injection without
imaging services. Our reviewer says that the requested procedure is not medically reasonable and necessary.
Our physician reviewer found the enrollee is an 89-year-old man with chronic low back pain from spinal
stenosis with neurogenic claudication. He has failed physical therapy and medication trials. The request is for
an epidural steroid injection, but the code used indicated that no imaging will be utilized. The standard of care
is the utilization of either fluoroscopic or CT guidance to perform an epidural steroid injection. Therefore, the
request is considered not medically reasonable or 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 an epidural steroid injection without imaging services have not been met.
Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection without imaging
services (62322)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute
setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Acute care
hospitals (ACH) and LTACHs are licensed to provide same level of service and there is no benefit in the
transfer. Clinical stability can be achieved in the current setting. An LTACH will not change the long or short
term outcome. An LTACH will not add any value based care. An LTACH will lead to futile care and increased
risk of complications. Our physician reviewer found that the enrollee's condition does not meet Medicare
criteria for LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on July 28, 2021.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not
covered under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.
The records do not show that you have been injured or directly exposed to any illness related to the vaccine.
Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on July 28,
2021.
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on July
12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that it was medically necessary for
the enrollee to receive treatment and you did not know that the facility failed to get preauthorization, so you
treated this enrollee anyway. The Plan denied your request. The Plan says enrollee's 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 domiciliary or rest home visit (99336)
provided on July 12, 2021 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 IRF care is medically reasonable and necessary. The
Plan denied your request. The Plan says rules for IRF care have not been met.
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 patient was admitted for acute respiratory failure, sepsis, and panniculitis and
was discharged home on November 8, 2021. She has had ongoing weakness and decline in function despite
home health services. Medical problems are stable. There are no complex nursing or rehabilitation needs. The
patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In
conclusion, there is not a reasonable expectation that this patient 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and
unspecified preventive service (D1999) provided on November 23, 2020.
You asked the Plan to pay for the dental services. You say that you were advised that the services would be
covered. You say that you have been receiving calls from a collection agency. You also say that you should not
be responsible for this bill. The Plan denied your request. The Plan says the provider in this case has opted out
of Medicare. The Plan also says that payment cannot be made for dental services performed by a dentist that
has opted out of Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network
are not among those covered under this benefit. Additionally, the record shows that the Plan advised a different
provider at this office was named as an in-network dentist. Therefore, we decided that the Plan does not have to
pay for the oral exam (D0120), prophylaxis (D1110), and unspecified preventive service (D1999) provided on
November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested monitor. You say that it is critical to monitor your blood sugar
daily. The Plan denied your request. The Plan says clinical documentation does not substantiate medical
necessity.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
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 assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing
results. Based on this information, we decided that Medicare rules for coverage of the requested monitor have
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.