Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health services provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve inpatient mental health services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says these services have been correctly denied. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health services. Our reviewer says that based upon review the records provided for the admission of this patient does not meet 
criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to herself or 
others, noted auditory at times no visual hallucinations. Our physician reviewer found the enrollee is noted to 
be cooperative and compliant with treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient mental health services provided by an out-of-network 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, at an intensive rehabilitation therapy program. You continue to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is 
no indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a 
week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional 
status. You can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 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 you appear to be somewhat unstable 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 you require 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
medical records show that the member does not need a higher level of care with an out-of-network provider. 
Member's must have special needs or medical problems such that a provider in the primary network cannot 
provide care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips for the 2022 calendar 
year, in excess of those provided by the Plan. 
 
You asked the Plan to provide additional transportation. You say that you need more transportation to get to 
your ongoing follow-up appointments. The Plan denied your request. The Plan says your benefit covers a 
maximum of 24 trips per year. Additional trips are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plan's maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transportation trips for the 2022 calendar year, 
in excess of those provided by the Plan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide 30 additional routine transportation trips for the 2022 
calendar year. 
 
You asked the Plan to provide additional transportation. You say that you need more transportation to attend 
your therapy sessions twice per week for six weeks. The Plan denied your request. The Plan says your benefit 
provides 30 one-way transportation trips per year. Additional trips are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year to locations other than your Primary Care Providers office.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plans maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide 30 additional routine transportation trips for the 2022 calendar 
year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic pill dispenser. 
 
You asked the Plan to pre-approve these services. You say that this will help you remember to take your 
medication. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve an electronic pill dispenser.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ongoing inpatient psychiatric admission and services. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the criteria for admission to an inpatient mental health 
setting are not met in this case. The enrollee can safely be treated in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer says that the health plan's denial of psychiatric services at the inpatient appears appropriate in this case. Our 
physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on 
March 15, 2022, with Schizoaffective Disorder and Borderline Personality Disorder. Based upon review the 
records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in 
question as she did not have suicidal or homicidal ideation or auditory or visual hallucinations. The enrollee 
was compliant with treatment while not showing any acute threats to safety. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care as she did not have dangerousness to self or others and was compliant with her treatment. It 
did not appear that active treatment was taking place beyond the date in question. It did not appear that the 
services were reasonably expected to improve the enrollees condition or for the purpose of diagnosis beyond 
the date in question. Based upon review of the records provided for this admission, the enrollee does not meet 
the criteria for June 6, 2022, forward. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ongoing inpatient psychiatric admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide an additional 48 routine transportation trips in 2022. 
 
You asked the Plan to provide additional transportation. You say that the Plan should cover more 
transportation. The Plan denied your request. The Plan says your benefit covers 24 one-way transportation trips 
per year. Additional trips are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide an additional 48 routine transportation trips in 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for future radiation therapy services. 
 
You asked the Plan to waive the copayments for the future radiation therapy. You say that you cannot afford 
the copayment each time the services is done. The Plan denied your request. The Plan says the cost sharing 
amount is a contractual obligation that cannot be waived. 
 
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 $60 
copayment per day for radiation therapy.  
 
Per the contract, there is a $60 copayment per day for radiation therapy. The future radiation therapy falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 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 copayments for future radiation therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic bone growth (osteogenesis) stimulator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that an ultrasonic osteogenesis stimulator is covered 
when there is x-ray documentation of a nonunion fracture, separated by 90 days. 
 
We looked at the file and Medicare rules. The file does not contain two x-rays separated by 90 days showing 
evidence of a nonunion fracture. The records contain only one x-ray. Therefore, we decided that the Plan does 
not have to pre-approve an ultrasonic bone growth (osteogenesis) stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you are unable to tell when your sugar is low. 
The Plan denied your request. The Plan says the criteria for coverage are not met. 
 
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 you do not treat with insulin three 
or more times per day or use an insulin pump. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you need the scooter for shopping and use in 
the community. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is no documentation that the enrollee requires the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C/Gammaked injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a requirement of a trial and failure of corticosteroids, and at least two or more 
immunosuppresive agents. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 injection. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the current 
guidelines say that maintenance IVIG can be used for ongoing therapy in myastehnia gravis for patients who do 
not respond adequately to other immunosupressive agents. The enrollee is not noted to fall within such a 
categorization. Rather, they have only tried low dose steroids and Mestinon. In as much IVIG would not be 
used ina  manner consistent with standards of care. Thus it would not be reasonable and necessary. Ongoing 
IVIG infusions have not otherwise been shown to be effective in ocular myasthenia gravis however. In as much 
the efficacy cannot be determined. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex-C/Gammaked injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the services should be covered as you disagree 
with the denial and would like to continue seeing the provider. The Plan denied your request. The Plan says the 
services denied correctly as they were non-emergent and can be provided by in-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided 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 pneumatic compressor and supplies and to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and supplies. You say that there is no in-network 
provider that carries the pump the physician is requesting in the patient's geographical area. The Plan denied 
your request. The Plan says this medically necessary care is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor and supplies and to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrical stimulators (A4556, A4595, E073) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the electrical stimulators. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and there are in-network providers who can provide these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
electrical stimulators (A4556, A4595, E073) to be provided by an out-of-network (OON) provider.