Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is well below his baseline and would 
benefit from SNF services. The Plan denied your request. The Plan says that the enrollee does not meet the 
requirements for a SNF 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has multiple functional deficits post-acute illness. The Plan has not 
provided records supporting rationale for denial. The enrollee's response to rehabilitation and function prior to 
the acute stay are not provided. The enrollee has medical conditions that require daily skilled therapy.  
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: 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 it is not safe for you to return home having no one 
to assist with needs. You need rehabilitation to get back to normalcy. The Plan denied your request. The Plan 
says the medical records do not show you require skilled nursing or therapy services that can only be provided 
on a daily inpatient basis. 
 
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 based on the documentation provided, you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are 
ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your 
care 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided by an out-of-network 
provider on August 15, 2023. 
 
You asked the Plan to pay for the home health services. You say that you have submitted additional 
documentation to support the medical necessity for these services due to continuity of care. The Plan denied 
your request. The Plan says these services were not emergent and were not approved in advance. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 home health services. Our reviewer says 
that these services were not necessary with an out-of-network provider. Our physician reviewer found the 
clinical documentation shows that the enrollee had medical comorbidities and required assessment/treatment 
through home health services, however it does not specify any urgent, emergent, or unique clinical scenario to 
support out-of-network care. The Plan has shown that the enrollee's necessary home health services would be 
able to be managed by an in-network home health care provider with the appropriate qualifications and 
expertise. The enrollee's medical management and follow-up care could have been safely transitioned to an in-
network home health provider. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided by an out-of-network provider on August 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a genicular nerve block is experimental for knee pain. 
 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
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 need IRF services. The Plan denied your 
request. The Plan says you do not meet the requirements for an 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 your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 does not support that you would meet 
criteria for admission to an acute IRF  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 
4, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says enrollees generally must receive their care from a 
network provider. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care provided on September 4, 2023, by an out-of-network 
(OON) 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 you need IRF services to return to being independent 
as quickly as possible. The Plan denied your request. The Plan says you do not meet the requirements for an 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Heelex low dose external beam radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. You say that the requested treatment is medically 
necessary due to primary osteoarthritis in the left hand. The Plan denied your request. The Plan says that the 
enrollee does not have cancer. The request is considered investigational and is otherwise not medically 
necessary and reasonable. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the literature and evidence on the use of modern low-dose radiation therapy in the treatment of 
osteoarthritis (OA) is growing. Many radiation oncology practices have started to offer this type of radiation to 
enrollees who do not want an invasive approach and/or have failed local therapies. This approach has also been 
used as a bridge to surgery in some cases. Given the radiation therapy dose used in this situation, the likelihood 
of causing any significant harm or serious acute or late radiation induced side effects is expected to be 
extremely low. Considering the nature of this condition and the difficulty in conducting clinical trials in this 
condition, the current published literature supports using low-dose radiation therapy in the treatment of this 
condition. The provider has cited a recent review article published in the peer reviewed American Society for 
Therapeutic Radiology and Oncology's (ASTROs) top journal dedicated to the field of radiation oncology. 
Therefore, the low dose external beam radiation therapy should exceptionally be approved for this enrollee 
knowing the absence of level I evidence and based on several published large case series. Using low-dose 
external beam radiation therapy is not considered investigational in this case and is medically reasonable and 
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 radiation therapy have been met. Therefore, we decided that the Plan has to pre-
approve Heelex low dose external beam radiation therapy.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion and allograft. 
 
You asked the Plan to pre-approve spinal fusion and allograft. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements 
for approval. 
 
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 spinal fusion and allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that fusion indications within guidelines/literature for (existing or potential 
intraoperative) instability have not been documented and/or met in this case. In addition, there are multiple 
alternate pain generators plausibly significantly contributing to the clinical condition that have not been fully documented as having been excluded and/or ruled out. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
L4-5 posterolateral arthrodesis with implantation of the Minuteman G3R Interspinous device is not medically 
reasonable or 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 spinal fusion and allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve spinal fusion and allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to wave the cost share for the office visits from January 5, 2023, to 
October 24, 2023. 
 
You asked the Plan to wave the cost share for the office visits. You say that you met your out-of-pocket 
maximum in July, but you are still receiving bills since then. The Plan denied your request. The Plan says the 
correct Annual Maximum Out-of-Pocket has been applied. 
 
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 $4,500 
maximum out-of-pocket for combined in-network and out-of-network covered Part A and Part B services.  
 
  You have met your $4,500 out-of-pocket maximum for the office visits. This item/service falls within the What 
is the most you will pay for Medicare Part A and Part B covered medical services benefit category. You met 
your maximum out-of-pocket on dates of service January 18, 2023, January 17, 2023, January 27, 2023, 
February 2, 2023, February 15, 2023, February 17, 2023, February 24, 2023, March 6, 2023, April 3, 2023, 
March 25, 2023, March 27, 2023, March 28, 2023, May 17, 2032, May 19, 2023, May 22, 2023, May 24, 2023, 
May 27, 2023, May 31, 2023, June 19, 2023, June 21, 2023, June, 23, 2023, June 26, 2023, June 30, 2023, July 
10, 2023, July 12, 2023, July 14, 2023, July 18, 2023, July 19, 2023, July 24, 2023, July 31, 2023, August 7, 
2023, August 17, 2023. 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 wave the cost share for the office visits from January 5, 
2023, to October 24, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services. The Plan denied your 
request. The Plan says you do not meet the requirements for an 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found your medical and rehabilitation needs do require the intensive interdisciplinary approach provided on 
acute inpatient rehabilitation. You do require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. You require minimal assistance for bed mobility and upper 
extremity daily activities. You also require maximum assistance for transfers, standing and toileting. You are 
functionally non-ambulatory. You have had a significant decline from your baseline level of function and 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric lift mechanism. 
 
You asked the Plan to pre-approve an electric lift mechanism. You say that an electric lift is medically 
necessary. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 an electric lift mechanism. Our  
 reviewer says that this item is not medically necessary. Our physician reviewer found you can rise from a chair 
independently. 
 
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 electric lift mechanism have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an electric lift mechanism.