Persius/hicric huggingface dataset:
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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on a review of the clinical 
documentation, inpatient rehabilitation facility admission is not reasonable and 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 complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve PVA. You say that you have documents such as CT and X-ray reports, 
showing that the enrollee has a compression fracture of her L3 vertebra. The Plan denied your request. The 
Plan says the medical criteria for this procedure 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 PVA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of a progression of the body height loss, greater than 25% vertebral 
body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is magnetic 
resonance imaging (MRI) corroboration of other plausible causes of 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 PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a percutaneous vertebral augmentation (PVA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 01, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 01, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy treatment provided on April 
19, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy treatment. You say that the enrollee met the 
maximum out-of-pocket and should not have a cost share. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare Part B chemotherapy drugs.  
 
The enrollee has been asked to pay $2,879.86 for chemotherapy treatment. This total is less than the standard 
coinsurance amount because the enrollees maximum out-of-pocket was met with the processing of this claim 
(14,556.78 allowed x 20% = $2,911.36). This item/service falls within the Medicare Part B prescription drugs 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy treatment 
provided on April 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of inpatient care provided from  
January 31, 2023, to February 2, 2023. 
 
You asked the Plan to pay for continuation of inpatient care. You say that continuation of inpatient care was 
medically necessary. The Plan denied your request. The Plan says continuation of inpatient care 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 continuation of inpatient care. Our reviewer 
says that continuation of inpatient care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was treated in the hospital for acute on chronic respiratory distress 
and was treated with intubation. On January 1, 2023 the enrollee was described as having been extubated, 
stable, tolerating room air and awaiting placement. Ongoing acute care hospital services were requested. 
However, the enrollee did not require ongoing acute care and was appropriate for a lower level of care from 
January 31, 2023 to discharge on February 2, 2023. Ongoing acute care is not supported in the provided 
documentation and will be considered 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 continuation of inpatient care have not been met. Therefore, we decided that the 
Plan does not have to pay for continuation of inpatient care provided from January 31, 2023, to  
February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor device (E0651) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor device and a garment. You say that the enrollee 
would face obstacles that would impair healing if forced to use the in-network provider. The Plan denied your 
request. The Plan says the enrollee must use network providers to get medical care and services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor device (E0651) and a segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Nalu device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature does not support this service to be reasonable 
and 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 pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clearance is not clear and complications cannot be eliminated. At this point, the procedure is not 
deemed 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Nalu device.
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 the enrollee will benefit from IRF services that 
cannot be provided at a lower level of care. The Plan denied your request. The Plan says the enrollee does not 
meet he 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 the enrollee's condition is in fact complex and fragile, and there is every reason to expect that he will 
participate in and benefit from IRF-level services to include at minimum physical therapy with pre-prosthetic 
training, occupational therapy, physician oversight of wound care, polypharmacy, lab values, and case manager 
coordination of any additional services that might be needed to make a sustainable return home, as well as 
avoid further readmissions to the acute hospital.  The Plans suggestion that his needs could be met in a lower 
level of care are wholly inappropriate. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99244) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the providers within a 50-mile radius are not 
suitable because you cannot be in a vehicle for extended amounts of time due to bladder incontinence issues. 
The Plan denied your request. The Plan says you must use network providers to get your medical care and 
services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99244) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found in this case there was only mention of 
possible AD versus other causative factors (such as vascular, obstructive sleep apnea). In as much the base 
requirement of the NCD for coverage would not be met. Our reviewer found that there was no mention of FTD 
or an indication that the enrollee met diagnostic criteria for both AD and FTD. Therefore, this request would 
not be 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
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 enrollee needs treatment to regain strength. The 
Plan denied your request. The Plan says based on Medicare guidelines, the SNF services requested do not meet 
the requirements for approval. 
 
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 the enrollee may require skilled nursing care for nasogastric (NG) tube feeding but 
long-term tube feeding via a percutaneous endoscopic gastrostomy (PEG) tube is not an option per the 
enrollees family. The enrollee does have some wound care needs, but other than this and temporary NG tube 
feeding, there are no other significant skilled nursing needs. The enrollee does not have rehabilitation needs 
and cannot participate in physical and occupational therapy services given their inability to consistently follow 
commands. The enrollee will require assistance with mobility and daily activities, but this does not require 
skilled therapy. The enrollee does 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 skilled nursing facility (SNF) care.
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 the IRF services are medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services requested do not meet the 
requirements for approval. 
 
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 the medical record overall significantly complies with the various documentation requirements for IRF 
admission. Indeed, this enrollees condition is in fact complex and fragile, and there is every reason to expect 
that they will participate in and benefit from IRF-level services to include at minimum physical therapy, 
occupational therapy, speech language pathology, physician oversight of polypharmacy and drain management, 
and case manager coordination of any additional services that might be needed to make a sustainable return 
home, as well as minimizing further preventable readmissions to the acute hospital. Our reviewer found that it 
is highly unlikely that the enrollee's needs could be met at a lower level of care. Our physician reviewer found 
that therefore, the requested IRF admission is approved. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee does not meet evidence-based criteria for the requested 
procedure. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease. The cause of pain is not clear. Criteria is not 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).