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 enrollee is stable and safe for 
discharge. You say that an LTACH will render services that will improve the enrollee's condition and avoid 
unnecessary hospital readmission, as well as an unnecessarily long stay at the short term acute hospital. The 
Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The 
Plan says that the level of care provided in an LTACH setting is more than the enrollee's medical conditions 
need. The Plan says that the enrollee can 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 does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. There are no services available at the LTACH that the enrollee requires that are not available 
at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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: Favorable

 
We decided that the Plan has to pre-approve an office visit for a kidney transplant evaluation. 
 
You asked the Plan to pre-approve an office visit for a kidney transplant evaluation. You say that an office visit 
for a kidney transplant evaluation is medically necessary. The Plan denied your request. The Plan says that an 
office visit for a kidney transplant evaluation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 an office visit for a kidney transplant 
evaluation. Our reviewer says that an office visit for a kidney transplant evaluation is considered medically 
reasonable and necessary in this case. Our physician reviewer found that there is no absolute cut-off for renal 
transplantation and differing transplant centers use different cut off BMI values. Typically, that number is 
40. Some centers will transplant patients above this number. It is of the opinion of the transplant screener that 
you are appropriate for the start of evaluation. Please note, everyone who gets screened and evaluated for 
transplant does not get a transplant, it is the start of a long process. You may end up being denied at the end of 
the evaluation. I agree with the decision of the transplant center that you are appropriate to begin workup for 
transplantation. 
 
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 office visit for a kidney transplant evaluation have been met. Therefore, we 
decided that the Plan has to pre-approve an office visit for a kidney transplant evaluation.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation (99243) with an oncologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office consultation. You say that the enrollee is not interested in surgery 
and would like a second opinion since treatment is very extensive. The Plan denied your request. The Plan says 
the requested provider is not contracted and is an out of network facility. There are qualified in-network 
oncologists that the enrollee can see. 
 
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 consultation (99243) with an oncologist 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 wrist-hand-finger orthosis (L3901). 
 
You asked the Plan to pre-approve a wrist-hand-finger orthosis. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested item have not been met. 
 
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 a wrist-hand-finger orthosis. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is insufficient evidence in the medical literature for the use of this 
device for rehabilitation after stroke. There is insufficient evidence in the literature for the use of dynamic 
splinting to improve outcomes following Botox injection for the treatment of limb spasticity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a wrist-hand-finger orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wrist-hand-finger orthosis (L3901).
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 an admission is medically necessary. The Plan 
denied your request. The Plan says an admission to an IRF 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 the enrollee was admitted for cervical spine surgery. Medical problems are stable and 
there are no complex nursing or rehabilitation needs. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 Reader and Sensor. 
 
You asked the Plan to pre-approve Freestyle Libre 2 Reader and Sensor. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not 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 Freestyle 
Libre 2 Reader and Sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve Freestyle Libre 2 Reader and Sensor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide transportation so that you may get to an appointment with 
your urologist. 
 You asked the Plan to provide transportation. You say that you do not have a way to get to this appointment 
and this transportation is necessary. The Plan denied your request. The Plan says the requested transportation to 
a provider's office is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to provide are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to provide transportation so that you may get to an 
appointment with your urologist.
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 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 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 admission are met in this 
case. Our physician reviewer found the record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. 
The elements of the coverage rule are not satisfied. The requested service is not 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlimited office visits (99205) for a stem cell transplant 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve unlimited office visits. You say that the enrollee was previously approved 
for a visit. The enrollee is needing unlimited consultations for treatment. The Plan denied your request. The 
Plan says care outside the health plan network will not be authorized unless that care is not available within the 
network. There are in-network providers who can provide the enrollee with the requested services that are 
needed. 
 
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 
unlimited office visits (99205) for a stem cell transplant to be provided by an out-of-network (OON) provider.
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 physician's services to be provided by the requested out-of-network 
provider. You say that you have seen this provider prior to enrolling with this Plan and you would like to 
continue seeing this provider. The Plan denied your request. The Plan says the doctor is not a network doctor. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dialysis services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received 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 
dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF are. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs or documented skilled therapy needs. The enrollee appears to be functioning at/near her 
baseline. Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of the enrollees condition.  The enrollees care needs can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you cannot find any providers in your 
local area. The Plan denied your request. The Plan says the requested services can be provided by a network 
provider. 
 
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 
pain management visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve a SCS trial. 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 follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
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 a SCS trial. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the records do not show that all treatment 
options have been tried and failed. The enrollee has not seen and been evaluated by a spine surgeon. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says a need for IRF care is not supported by the records received. The 
Plan says that they suggest care in a skilled nursing facility, based on the enrollee's current needs. 
 
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 is 
living at home with myopathy, end stage renal disease, congestive heart failure, an neuropathy and has had 
episodes of falling. 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 medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 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.