Persius/hicric huggingface dataset:
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 more stable and improving and should only require short-
term additional acute care services that can be safely administered at the current facility until more 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 it would not be 
clinically advantageous at this time. Completion of treatment at the current facility 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 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: 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 for 
the enrollee's condition. 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 enrollee has a chronic deconditioned state without significant neurological injury. It is unclear from the record why she is functioning at a low level. A post-acute deconditioned state with 
functioning cognition without behavior disturbance, incontinence, or neurological impairment with autonomic 
instability is not evidence of a complex or intensive rehabilitation need. The vast majority of persons who 
decondition during hospital stay rehabilitate without admission to an IRF. No indication for frequent physiatry 
oversight. The request is not reasonable and necessary as it is not consistent with evidence based or clinical 
practice standards. 
 
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 the clinical information provided 
supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage 
have not been met. The Plan says that the enrollee can safely receive the care needed 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 the enrollee was admitted to the acute care hospital with septic shock, bowel 
obstruction, and bacteremia treated with laparotomy with lysis of adhesions and small bowel resection, 
antibiotics, diuresis, amiodarone drip for atrial fibrillation, and NG tube feeds. Recent notes describe the 
enrollee as having a poor prognosis and hospice is being arranged. The enrollee appears to be more stable and 
improving and should only require short-term additional acute care services that can be safely administered at 
the current facility until more appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. Transfer to an LTACH is not medically necessary as it would not be clinically advantageous at this time. Completion of treatment at the current facility 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on October 15, 
2021, to October 16, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you didn't think there would be 
a copayment. The Plan denied your request. 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 $400 
copayment for all other outpatient services not provided in an ambulatory surgical center. 
 
 
 
 
 You have been asked to pay $400 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided 
on October 15, 2021, to October 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not reasonable or necessary at this time. 
 
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 Keytruda. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of stage IIB 
adenocarcinoma of the lung. It is noted that the tumor is PD-L1: Negative; EGFR expression: Negative; KRAS 
gene: Wild-type; and BRAF Mutation: Wild-type. The enrollee has evidence of locally advanced disease with 
mediastinal lymph node involvement. It is noted that the enrollee will not accept chemotherapy, and that a plan 
of treatment for Keytruda was placed. The requested use of Keytruda is not FDA approved for the enrollee's 
diagnosis, as it is for treatment of non-small cell lung cancer with PD-L1 expression. The enrollee is PD-L1 
negative. The use of single agent Keytruda for the treatment of the enrollee's condition is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The 
documentation does not support the Keytruda is safe and effective and otherwise reasonable and necessary for 
the enrollee 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for drugs provided on March 3, 2022. 
 
You asked the Plan to waive the coinsurance for drugs. You say that you thought this was going to be covered. 
The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare Part B covered drugs.  
 
You have been asked to pay $613.03 which is 20% of the allowed amount for drugs. The allowed amount is 
$3,065.03 (20% x $3,065.03 = $613.03). Drugs fall within the Medicare Part B Prescription Drugs benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for drugs provided on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that your son referred you to this physician and you 
were not aware there would be an issue with coverage. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on January 12, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on March 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the Plan should cover this routine laboratory 
work that was ordered by your primary care doctor. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. Therefore, 
we decided that the Plan does not have to pay for the laboratory work provided on March 24, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
(K0553). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that although you do not take insulin, you 
believe that a CGM will help avoid that situation. The Plan denied your request. The Plan says you do not meet 
prior authorization criteria. 
 
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 indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 continuous glucose monitor (CGM) (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have cognitive impairment, and you 
are forgetful of the date, time, & place, therefore your doctor deemed it necessary for your diagnosis and 
treatment The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies..
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 home test kits purchased from February 7, 
2022, through February 9, 2022. 
 
You asked the Plan to pay for the COVID-19 home test kits. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says these tests are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 home test kits are OTC items. The Plan had no supplemental coverage for COVID-19 home test 
kits when they were purchased. Therefore, we decided that the Plan does not have to pay for the COVID-19 
home test kits purchased from February 7, 2022, through February 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 2, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you had no choice but to have an 
ultrasound and you shouldn't be penalized for it. The Plan denied your request. 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 $35 
copayment for each Medicare covered x-ray.  
 
You have been asked to pay $35 copayment for an ultrasound. Ultrasounds 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 an ultrasound provided on April 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care provided from 
November 12, 2021, through December 11, 2021. 
 You asked the Plan to pre-approve the SNF care. You say that SNF care was medically reasonable and 
necessary on the dates in question. The Plan denied your request. The Plan says rules for SNF care have not 
been met. 
 
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 
the SNF care was not medically reasonable and necessary. Our physician reviewer found the beneficiary is a 
95-year-old female with dementia, hypertension, diabetes and chronic kidney disease. In this case, there were 
no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In conclusion, 
this beneficiary did 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care provided from November 12, 2021, through December 
11, 2021.
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 stabilizing and should only require short-term additional 
acute care services that can be safely 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 it would not be clinically 
advantageous at this time. Completion of treatment at the current facility 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemcitabine HCL, Paclitaxel Proteinbound Particles, 
and Metoclopramide HCL. 
 You asked the Plan to pre-approve Gemcitabine HCL, Paclitaxel Proteinbound Particles, and Metoclopramide 
HCL. You say that the requested drugs are medically necessary. The Plan denied your request. The Plan says 
the requested drugs would be a cost covered by the Medicare Administrative Contractor (MAC) because the 
enrollee is enrolled in a clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Gemcitabine HCL, Paclitaxel Proteinbound Particles, and 
Metoclopramide HCL as part of a clinical trial. The Plan does not cover routine costs associated with 
qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Gemcitabine HCL, 
Paclitaxel Proteinbound Particles, and Metoclopramide HCL.
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 enrollee clearly meets the LTACH 
criteria. You say that the enrollee can recovery outside of an ICU setting but requires a multi-disciplinary team 
experienced in working with chronically, critically ill patients who require a longer hospitalization. The Plan 
denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the 
enrollee's care can be provided in the current inpatient hospital. 
 
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 was admitted to the acute care hospital with acute respiratory failure due 
to pneumonia and septicemia requiring mechanical ventilation support, antibiotics, wound care, and 
complicated by encephalopathy, atrial fibrillation with RVR. Recent notes describe the enrollee as now 
tolerating low dose supplemental oxygen during the day and BiPAP at night, on IV Cardizem and Zosyn, 
receiving daily wound care, and with a new rectal tube. The enrollee has been still experiencing somnolence and confusion, pulling out NG tube and lines. The enrollee appears to be somewhat unstable and requires short-
term additional acute care services that can be safely administered at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to LTACH is not medically necessary as the patient is not yet stable 
for transfer and as it would not be clinically advantageous at this time. Completion of treatment at the current 
facility 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 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.