Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care provided from November 8, 
2020, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided, for the admission of this patient does not 
meet the criteria for acute inpatient mental health treatment as this patient had passive danger to themselves 
with no plan but not others and was without agitation or aggression without perceptual disturbance including 
auditory or visual hallucinations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care provided from November 8, 2020, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve progressive lenses (V2781), deluxe lenses (V2702), and 
deluxe frames (V2025). 
 
You asked the Plan to pre-approve the eyewear. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested eyewear is not a covered benefit under your 
contractual policy. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan only covers one pair of glasses after cataract 
surgery and does not cover eyewear upgrades or enhancements that are not medically necessary or covered by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve progressive lenses (V2781), deluxe 
lenses (V2702), and deluxe frames (V2025).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and testing provided on October 23, 2019. 
 
You asked the Plan to pay for the office visit and testing. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit and testing provided on October 23, 2019
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 disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital with intraparenchymal hemorrhage with left-sided hemiparesis and facial droop following a suspected 
fall with associated acute respiratory failure. She appears to be stable but requires additional short-term acute 
care services to help initiate ventilation weaning attempts, which can be safely completed in the current setting. 
She does not require LTACH services that are not already available at the current facility. There are no services 
at the LTACH that she requires that are not already available and covered at the current setting. The LTACH 
services are not reasonable or 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 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: 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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but 
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy 
program. There is no documentation that the patient requires the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more 
appropriate in this case. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 health plan's denial of LTACH coverage 
should be upheld. You are currently undergoing treatment at an ACH for bilateral lower extremity ulcers. You 
are not intubated/ventilated. There is no evidence that you require services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to 
the LTACH. You can remain at the current ACH until such time no acute services are required. You can then 
be transferred/discharged to a lower level of care for any ongoing LTC needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device (CPT Codes: C2624 and 33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the device is necessary. The Plan 
denied your request. The Plan says that the device is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS device. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient has Class III congestive heart failure (CHF) and multiple recent 
admissions for congestive heart failure. The patient has dyspnea at baseline as well and evaluation of clinical 
fluid status has been difficult per the medical records. The patient is on a complex medical regimen and is very 
sensitive to volume status. The patient also has significant renal insufficiency making diuretic management 
more difficult. CardioMEMS device implantation has been shown in randomized trials and is FDA approved 
for the management of patients meeting these clinical criteria to decrease recurrent hospitalizations for CHF 
and improve quality of life. This patient requires close monitoring of filling pressures and volume status (which 
has proven difficult by exam and weight alone) to improve symptoms and decrease recurrent hospitalization. 
Based on the patient's clinical status, clinical diagnosis and recurrent recent hospitalizations for CHF 
exacerbation, the patient meets FDA, published randomized data and CMS criteria for the use of the 
CardioMEMS pulmonary pressure monitoring device for this clinical situation. 
 
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 CardioMEMS device have been met. Therefore, we decided that the Plan 
has to pre-approve the CardioMEMS device (CPT Codes: C2624 and 33289).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on May 22, 2020. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you were unconscious and did not 
request this service. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area.  
 
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we 
decided that the Plan does not have to pay for the paramedic intercept services provided on May 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 10, 
2020. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that you went to this provider 
because your dentist could not do the extraction. You say that you are appealing the denial. The Plan denied 
your request. The Plan says a limited exam is only covered once per plan year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one limited exam per plan year. The Plan paid for a limited oral evaluation (D0140) provided on July 9, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on July 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darbepoetin alfa (Aranesp). 
 
You asked the Plan to pre-approve the Aranesp. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 the Aranesp. Our reviewer says that 
Aranesp does not meet the Plan's coverage criteria. Our physician reviewer found the enrollee has not yet tried 
Retacrit. Our reviewer also found that the use of Darbepoetin is not reasonable or 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 Aranesp have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Darbepoetin alfa (Aranesp).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power recline with sheer reduction, power center 
mount legrests, wheelchair access manual swingaway other control interface, thru drive control with 2 
actuators, attendant control, switch-it versaguide, joystick custom configured push handles for trailing and a 
candy purple shroud. 
 
You asked the Plan to pre-approve these items. You say that you would like these items to be approved. The 
Plan denied your request. The Plan says that the records don't support medical necessity for this equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 these items. Our reviewer says that a 
power recline with sheer reduction, power center mount legrests, wheelchair access manual swingaway other 
control interface, thru drive control with 2 actuators, attendant control, switch-it versaguide and joystick 
custom configured push handles for trailing are not considered medically reasonable and necessary in this case. 
There are no medical records were provided documenting necessity of the power recline with sheer reduction 
and power center mount legrests features. The available medical records do not show that the enrollee is unable 
to control the wheelchair or that he is unable to use a regular joystick that comes with the wheelchair. Our 
physician reviewer found that these items are not medically reasonable and necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. The candy purple shroud at issue in this 
appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public 
and would be helpful even to those who are not sick or injured. Based on this information, we decided that 
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power recline with sheer reduction, power center mount legrests, wheelchair access 
manual swingaway other control interface, thru drive control with 2 actuators, attendant control, switch-it 
versaguide, joystick custom configured push handles for trailing and a candy purple shroud.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed and a commode. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical notes do not show that the guidelines have been met. 
 
The Plan must follow Medicare rules. The rules say that a commode is covered when the beneficiary is 
physically incapable of utilizing regular toilet facilities. The rules say that a semi-electric hospital bed may be 
considered medically necessary when the patient: 
 
 
 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 items. Our reviewer says that the 
requested items are not medically reasonable or necessary. Our physician reviewer found you live in a single-
story home with a bathroom on the same level, so the you are not incapable of using regular toilet facilities. 
The documentation does not clearly reveal that your condition has failed positioning of the bed in ways not 
feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does 
not support a need for an immediate of frequent change in body position or special attachments that cannot be 
fixed on an ordinary bed. The head of the bed does not need to be elevated more than 30 degrees most of the 
time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. The request for a 
semi-electric hospital bed is 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a semi-electric hospital bed and a commode.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says criteria for 
SNF care has not been met. The Plan also says that care can be provided at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 you do not meet the Medicare criteria for SNF care. 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 SNF setting. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. 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 SNF 
admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nebulizer with compressor (E0570). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical records do not provide any explanation as to the necessity of a nebulizer device with battery 
as opposed to the covered nebulizer device that uses an outlet. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a nebulizer with compressor (E0570).