Persius/hicric huggingface dataset:
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 SNF care is medically necessary. The enrollee 
needs two people to help her sit and stand up. The Plan denied your request. The Plan says the SNF care is not 
medically necessary, and the enrollee's needs may be met at a lower level of care such as a long-term care 
setting. 
 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has no identifiable skilled nursing service needs and no identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis.  As a practical matter, the 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 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 infusion services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve infusion services. You say that this is the only provider that can perform the 
needed service. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and 
the enrollee can be treated by an in-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 
infusion services 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 back brace to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a back brace to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 back brace to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is not medically necessary for the enrollee. The 
Plan denied your request. The Plan says that admission to IRF was denied as not meeting AIR criteria, not 
medically necessary, and a lower level of care might be appropriate. SNF level of care was offered. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found enrollee is documented to be at high risk for complications thus IRF criteria met.  
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the 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 that the enrollee has had a functional decline from her baseline level of function and 
would likely benefit from occupational and physical therapies, but she does not require the intensity of 
therapies provided on acute inpatient rehabilitation. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips. The Plan denied your 
request. The Plan says you have used 50 trips and have 2 remaining. 
 
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 52 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 pre-approve additional non-emergency transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have pain, and the orthotic shoe can help 
with lift the ball of your foot, this would allow the toes to drop to assist with pinched nerve. The orthotic will 
release the pressure of the nerve. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth device to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a bone growth device to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 bone growth device to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Foundation One CDx testing provided on July 14, 2021. 
 
You asked the Plan to pay for the Foundation One CDx testing. You say that this testing was medically 
necessary and should be paid. The Plan denied your request. The Plan says this testing was not medically 
necessary. 
 
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 pay for the Foundation One CDx testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Foundation One Liquid CDx is a blood-based test or, "liquid biopsy," 
that tests circulating tumor DNA (ctDNA) that can be released from cancer cells into the bloodstream. It can be 
performed from a simple blood draw. The review indicates that the enrollee underwent a liver biopsy on June 29, 2021, with final diagnosis of poorly differentiated adenocarcinoma with neuroendocrine and mucinous 
features, noted as concerning for goblet cell adenocarcinoma. The records indicate the enrollee had a liver 
biopsy performed, but do not specify whether there was recurrent, relapsed, refractory, metastatic, or advanced 
stage III or IV cancer, prior genetic testing performed, or have made a decision to seek further treatment. 
Therefore, this testing was not medically necessary. 
 
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 Foundation One CDx testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the Foundation One CDx testing provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroco/Apap. 
 
You asked the Plan to pre-approve Hydroco/Apap. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydroco/Apap.  
 
Benefits for Hydroco/Apap may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of a peripheral or gastric 
neurostimulator pulse generator. 
 
You asked the Plan to pre-approve insertion or replacement of a peripheral or gastric neurostimulator pulse 
generator. 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 effective January 1, 2002, sacral nerve stimulation is 
covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. 
 
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 insertion or replacement of a peripheral 
or gastric neurostimulator pulse generator. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the enrollee does not meet the coverage criteria detailed in the NCD. Prior to sacral 
neuromodulator implantation the enrollee must have had a successful temporary test stimulation trial and 
completed a 3-day voiding diary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion or replacement of a peripheral or gastric neurostimulator pulse 
generator have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion or 
replacement of a peripheral or gastric neurostimulator pulse generator.
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 ready to transfer to the 
LTACH. The Plan denied your request. The Plan says the LTACH is not medically necessary, and the 
enrollee's needs are being met 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, 
pneumonia, epidural abscess, discitis, bacteremia, sepsis, encephalopathy, alcohol withdrawal, and 
cerebrovascular accident (CVA). The enrollee was treated with antibiotics, mechanical ventilation support, 
trachea placement, (percutaneous endoscopic gastrostomy) PEG placement, and alcohol detoxification 
treatment. The enrollee appears to be more stable and improving and should only require short-term additional 
acute care services that can safely be provided at the current facility until more appropriate for 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 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 Adlarity tablets. 
 
You asked the Plan to pre-approve Adlarity. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by 
Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Adlarity tablets.  
 
Benefits for Adlarity may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says a referral/authorization was not obtained prior to services being rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on July 18, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you suffer from Parkinson, COPD and Dementia. 
You are unable to get up and go to the bathroom on your own. You are testing positive for COVID and are 
currently a fall risk, You will need to be able to get up on your own using your walker before you can discharge 
home. Being discharged home at this time would not be safe for you. The Plan denied your request. The Plan 
says inadequate care givers support would not constitute a skilled nursing or therapy need. As noted, the assistance that you needs is that which a friend, family member, or hired caregiver can this. This is custodial 
and would not warrant skilled nursing facility admission. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for posterior tibial neurostimulation 
procedures provided from January 21, 2022, to February 18, 2022. 
 
You asked the Plan to waive the copayments for posterior tibial neurostimulation procedures. You say that the 
copayment is too high, and you were told that the procedure would be covered. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for each Medicare-covered outpatient hospital surgery visit.  
 
 
  You have been asked to pay a total copayment of $1,471.10 for posterior tibial neurostimulation procedures.  
The total includes a $294.22 copayment for each visit, which is less than the standard $350 copayment 
($294.22 copayment per visit x 5 visits = $1,471.10). This item/service falls within the Outpatient Hospital 
Services 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 copayments for posterior tibial 
neurostimulation procedures provided from January 21, 2022, to February 18, 2022.