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 need IRF care so you can recover. The Plan 
denied your request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Therapy (77300, 77334, 77387, G6002). 
 
You asked the Plan to pre-approve Proton Beam Therapy. You say that the requested therapy is medically 
necessary. The Plan denied your request. The Plan says there is no current research showing that the enrollee's 
type of cancer responds better to the requested type of treatment than the type of treatment we can approve. 
 
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 Proton Beam Therapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found There is no clear evidence that proton beam therapy for prostate cancer offers any 
clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a 
possible advantage of this expensive therapy. To date, there are no compelling data to suggest that proton 
therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate 
cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Proton Beam Therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Proton Beam Therapy (77300, 77334, 77387, G6002).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information we have about the 
enrollee's condition; the enrollee does not meet all the requirements. 
 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 reviewer says that 
SNF services are not medically necessary. Our physician reviewer found that the clinical documentation shows 
that the enrollee does have complex medical care needs and would benefit from skilled nursing. The clinical 
documentation also shows that enrollee has some functional impairment and would benefit from skilled 
therapy. The clinical documentation does not show that the enrollee requires skilled therapy or skilled nursing 
on a daily basis in a skilled nursing facility and the evaluating therapist recommend that skilled services in a 
home or outpatient setting is appropriate. 
 
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 SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but is still somewhat unstable (mental status, 
hyponatremia) and should only require short-term additional acute care services that can safely be administered 
at the current facility until more stable and appropriate for a lower level of care. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to 
LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on April 
18, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you did not see this provider. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 a $40 
copayment for each specialist visit.  
 
The records show that specialist services were provided on April 18, 202. Therefore, you have been asked to 
pay a $40 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner Services, 
Including Doctor's Office Visits 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 a 
specialist office visit provided on April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralight wheelchair. 
 
You asked the Plan to pre-approve ultralight wheelchair. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because 
the record does not show that the enrollee's needs cannot be met by a different manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules state that an ultralight wheelchair is only covered if certain 
criteria are met. 
 
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 ultralight wheelchair. Our reviewer says 
that the enrollee does not meet the Medicare criteria for an ultralight wheelchair. Our physician reviewer found 
the documentation does not show what assistive devices are required or have been tried, thus an ultralight 
wheelchair is not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultralight wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an ultralight wheelchair.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. The Plan denied your request. The Plan says that the enrollee does 
not meet the requirements for approval. 
 
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 Procrit. Our reviewer says that Procrit 
is medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of anemia of chronic kidney disease. The FDA has stated that the requested drug is indicated in 
patients for the treatment of anemia due to chronic kidney disease. Our reviewer also found that the elements of 
the coverage criteria are satisfied, and the requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have been met. Therefore, we decided that the Plan has to pre-approve 
Procrit.  
 
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 reduce the copayment for outpatient surgery performed on April 29, 
2022. 
 
You asked the Plan to reduce the copayment for outpatient surgery. You say that you would like to only be 
assessed the copayment for outpatient surgery at an ambulatory surgical center. The Plan denied your request. 
The Plan says the copayment was applied correctly. 
 
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 $325 
copayment for outpatient surgery.  
 
You have been asked to pay $325 for outpatient surgery. Outpatient surgery falls within the Outpatient Hospital 
Services benefit category. Please note, the facility where this procedure was rendered is not considered an 
ambulatory surgical center. 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 reduce the copayment for outpatient surgery 
performed on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical x-ray (D0220) provided on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your 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 exhausted on date of service March 31, 2022. 
Therefore, we decided that the Plan does not have to pay for a periapical x-ray (D0220) provided on April 26, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve grocery services. 
 
You asked the Plan to pre-approve grocery services. You say that you qualify for these benefits based on your 
medical condition. The Plan denied your request. The Plan says the criteria for coverage of these special 
supplemental benefits for the chronically ill. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. The Plan 
provides a supplemental benefit for special supplemental benefits for the chronically ill, including groceries. 
The Plan contract says that you may be eligible for these benefits if you have one of the following chronic 
illnesses: Cardiovascular Disorders (Cardiac Arrhythmias, Coronary Artery Disease, Peripheral Vascular 
Disease, Chronic Venous Thromboembolic Disorder), Chronic Obstructive Pulmonary Disease (COPD), 
Congestive Heart Failure (CHF), Dementia, Diabetes, and Stroke. 
 
We looked at the file and Medicare rules. In this case, you do not have one of the chronic illnesses required for 
coverage. Based on this information, we decided that Medicare rules for coverage of grocery services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve grocery services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammogram provided on 
December 23, 2021. 
 
You asked the Plan to waive the copayment for diagnostic mammogram. You say that this was supposed to be 
a screening mammogram. The Plan denied your request. This was charged as a diagnostic mammogram due to 
personal history of cancer. The Plan says the copayment applied 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 $45 
copayment for each basic imaging service (e.g., general x-rays or ultrasound).  
 
You have been asked to pay $45 copayment for diagnostic mammogram. Diagnostic mammograms fall within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 diagnostic mammogram provided on December 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance imaging (MRI) of 
the lumbar spine provided on March 27, 2022. 
 
You asked the Plan to reduce the copayment for the MRI. You say that you were informed the copayment 
would only be $100. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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 a $250 
copayment per day for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay $194.53, which is less than the $250 copayment for the MRI. The MRI falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 reduce the copayment for a magnetic resonance imaging 
(MRI) of the lumbar spine provided on March 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of authorization for 
acute inpatient rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about the enrollee's condition they do not meet the requirements. 
 
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 has a past medical history of surgical repair of a hip fracture, B cell 
lymphoma, and oxygen dependence and is living at home with weakness. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Medically necessary care 
can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on May 15, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you were not conscious. You say that the 
ambulance was called for assistance. You say that you eventually came back to consciousness and no longer 
required a trip to the hospital. The Plan denied your request. The Plan says since there was no transport 
provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 15, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on May 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the Centers for 
Medicare & Medicaid Services guideline criteria for admission to long term acute care. The Plan denied your 
request. The Plan says admission to the LTACH was denied as not meeting criteria, is not medically necessary, 
and continued acute hospital stay was offered, until the enrollee could discharge to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available where they are 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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation to learn to walk 
again. The Plan denied your request. The Plan says based on the clinical information you do not meet the 
Medicare criteria for inpatient rehabilitation facility admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found you were admitted for rhabdomyolysis and leg pain after a fall. Medical 
problems are stable. 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. Medically 
necessary care can be provided in a different 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 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.