Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 4 home health skilled nursing visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 4 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has 
determined that the records do not show that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not 
show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to 
improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the 
enrollee's level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 home health skilled nursing visits.
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 would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria for coverage of the IRF care. 
 
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's right hip fracture as described above, does not meet CMS coverage criteria for IRF admission. The enrollee is medically stable does not need PM&R physician supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. No acute rehab nursing needs identified or documented in the record. The enrollee does not need 
intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee appears to not be stable enough for 
transfer at this time. Acute care services can be safely administered at the current facility for the time being 
until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for coverage of the requested SNF care. 
 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 admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found this enrolle does 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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) admission.
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 would like reconsideration because the IRF 
admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for IRF 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for altered mental status and sepsis. 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. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on October 7, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 71045 may be eligible for payment when billed with code 71046. The claim does not 
show the code at issue was billed with a modifier suitable for payment. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the chest x-ray provided on October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power wheelchair (K0801). 
 
You asked the Plan to pre-approve a heavy-duty power wheelchair. You say that the item is medically 
necessary. The Plan denied your request. The Plan says you do not meet the weight requirements for this 
scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that the beneficiarys weight must be is less than or 
equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight 
capacity of the next lower weight class POV.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty power wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy-duty power wheelchair (K0801).
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 would like reconsideration because the 
requested IRF services are medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the requested IRF services. 
 
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical management of a cervical spine fracture after a fall. Your medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. You say that the items are medically 
necessary. The Plan denied your request. The Plan says you are not on insulin. 
 
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 
Freestyle Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14-day sensor
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission provided by a 
network facility. 
 
 
 
 You asked the Plan to pre-approve the SNF admission. You say that you are ready to be discharged from the 
hospital and on to the next step. You say you need physical therapy and a rehabilitation center to improve. The 
Plan denied your request. The Plan says authorization denied because the SNF admission is not medically 
necessary and your needs can be met at a lower level of care such as home with home health, in residential 
care, or home with close follow-up with his doctor. 
 
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 admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled 
nursing service needs that require skilled nursing services, including the specialized skill, knowledge and 
judgment of a skilled professional nurse required to safely and effectively provide medically necessary and 
reasonable treatment. There are identifiable skilled therapy service needs that require skilled therapy services, 
including the specialized skill, knowledge and judgment of a qualified therapist required to safely and 
effectively provide medically necessary and reasonable treatment. You do not require skilled nursing or therapy 
services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service 
criteria that require the necessary services on 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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission provided by a network facility.
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 you would like reconsideration because 
the LTACH services are medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet Medicare criteria for coverage of the LTACH services. 
 
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 should only require short-term additional 
acute care services that can be safely administered at the current facility until arrangements for home care or 
lower level of care to help manage ongoing ventilation support. The enrollee does not require services at the 
LTACH that are not already available at the current 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 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 Rituxan. 
 
You asked the Plan to pre-approve Rituxan. The Plan denied your request. The Plan says there is no 
documentation of a history of use of at least one preferred product resulting in a substandard response to 
therapy or a history of intolerance or adverse event to at least one preferred product. 
  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Rituxan. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found that the provided records do not indicate that the enrollee has tried and failed the 
plan's preferred step one alternative. The records do not indicate that the enrollee has a contraindication to or 
would have an adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and related 
accessories. 
 
You asked the Plan to pre-approve a wheelchair and accessories. You say that the item is medically necessary. 
The Plan denied your request. The Plan says Medicare does not cover wheelchairs if the member is in a facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and related 
accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 support surface (E0277). 
 
You asked the Plan to pre-approve a group 2 support surface. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the medical record does not indicate pressure ulcers or a recent 
myocardial flap or skin graft. 
 
The Plan must follow Medicare rules. Medicare rules say that when the stated coverage criteria for a group 2 
mattress or bed are not met, a claim will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 support surface have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a group 2 support surface (E0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the member is not insulin treated with atleast three injections a day. 
 
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 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-home laboratory services. 
 
You asked the Plan to pre-approve in-home laboratory services. You say that it is medically necessary for you 
to receive these services at your home. The Plan denied your request. The Plan says there are in-network 
providers available that would be sufficient for your laboratory needs. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve in-home laboratory services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) supplies 
(K0553) 
 
You asked the Plan to pre-approve the CGM supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says you are not on insulin. 
 
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 
the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) supplies (K0553)