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 moving from a hospital environment is not for the 
best. You say that the providers and staff at the requested facility are more familiar with your medical history 
and care plan. You say that you are a high fall risk and that not receiving care in the IRF would cause a major 
setback in your journey to recovery. You say that you are at higher risk of becoming infected with COVID-19 
if being moved to a skilled nursing facility. The Plan denied your request. The Plan says the guidelines for 
coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the care needed in a 
less intensive setting. 
 
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 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 coronary artery bypass grafting. The enrollee's medical conditions are stable. There are no 
medical needs requiring inpatient admission. 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. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not 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. 
 
 
 
 
 
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services with a Licensed Clinical Mental Health 
Counselor. 
 
You asked the Plan to pre-approve services with a Licensed Clinical Mental Health Counselor. You say that 
you do not want to change therapists. The Plan denied your request. The Plan says Licensed Clinical Mental 
Health Counselors are not a provider type recognized by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Licensed Clinical Mental Health counselors are 
ineligible to bill Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient mental health care not been met. Therefore, we decided that the Plan does not have to 
pre-approve services with a Licensed Clinical Mental Health Counselor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says truncal/abdominal/chest swelling is not documented. 
 
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 the documentation does not support that this enrollee has lymphedema of the chest, trunk, or abdomen. 
The enrollee does not have unique characteristics that would indicate the segmented pump over a standard 
pump. There is no documentation of a four week trial and failure of the standard pump with detailed 
measurements pre and post trial.  
 
The criteria for an E0652 pump has not been met per Local Coverage Determination (LCD): Pneumatic 
Compression Devices (L33829). 
 
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 a segmented pneumatic compression device for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
December 30, 2020. 
 
You asked the Plan to pre-approve the continued SNF care. You say that you believe that the enrollee has not 
received the amount of therapy she required due to COVID restrictions. The Plan denied your request. The Plan 
says the enrollee no longer requires daily skilled care to manage her condition. 
 
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 continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who 
was admitted to a SNF on 11/22/202 after treatment in the hospital for altered mental status. She was weak and 
deconditioned and was working with physical and occupational therapy. She was walking 20-55 feet with 
minimum to contact guard assistance with a walker and was minimum assist for transfers and maximum assist 
for lower body activities of daily living. She was reported to be medically stable as of 12/30/2020.  
 
Based on the medical records provided, there is no documentation that the patient requires skilled 
nursing/therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse/therapist is not required to safely and effectively provide medically necessary and reasonable treatment. 
The enrollee no longer requires daily skilled 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says criteria is not met for this complex level of 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 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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says 
mastectomy sleeves are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. A mastectomy sleeve does not meet the definition of a prosthesis. 
Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) services. 
 
You asked the Plan to pre-approve the CT scan. You say that  The Plan denied your request. The Plan says the 
enrollee does not have the medical necessity to have the requested CT performed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our reviewer says that the 
requested CT scan is not medically reasonable and necessary Our physician reviewer found the enrollee 
presented with a 25-pound weight loss. She had a workup with an upper GI endoscopy and colonoscopy, which 
were all normal. A chest x-ray and CT of the abdomen/pelvis were all negative. The enrollee has been a non-
smoker. There is no clinical rationale for the requested CT study. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on January 30, 
2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
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 the domiciliary or rest home visit provided on January 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide or certified nurse assistant and ground 
mileage provided from June 16, 2020, to July 23, 2020. 
 
You asked the Plan to pay for the home health aide or certified nurse assistant and ground mileage. You say 
that you fell and needed to have two surgeries. You also say that you needed assistance with every day duties 
after the surgeries, as well as transportation to and from the doctors. The Plan denied your request. The Plan 
says you received home health aide services from a provider who is not under contract with the Health Plan, 
and is not certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health aide or certified nurse assistant and ground mileage have not been met. This 
provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not 
have to pay for the home health aide or certified nurse assistant and ground mileage provided from June 16, 
2020, to July 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you are at risk for 
relapse if you are discharged. The Plan denied your request. The Plan says that you have no acute symptoms 
that require 24 hour care. 
 
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 psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. As of 
January 5, 2021 forward as you were not shown to be a danger to yourself or others. You were not showing any 
auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats 
to your safety as you await skilled nursing placement. Our physician reviewer found that your condition does 
not meet Medicare criteria for inpatient psychiatric hospital services. 
 
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 psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services needed could be provided in another setting. 
 
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 you are currently undergoing treatment at an ACH for polytrauma after being struck 
by a vehicle. 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 the enrollee 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 
long term care 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 admission to a long term acute care hospital (LTACH).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of a lower extremity 
(73721). 
 
You asked the Plan to pre-approve an MRI of a lower extremity. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of a lower extremity. Our 
reviewer says that the services are medically necessary. Our physician reviewer found review of the chart 
shows x-rays have been done which reveal a joint effusion. She has decreased range of motion and an effusion 
which are findings providing valid criteria for MRI of the knee absent a trial of conservative management. 
 
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 MRI of a lower extremity have been met. Therefore, we decided that the 
Plan has to pre-approve a magnetic resonance imaging (MRI) of a lower extremity (73721).  
 
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 the RT300 functional electrical stimulator system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a piece of exercise equipment, and it is not medical in nature. 
 
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 system. Our reviewer says that the 
requested system is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the evidence for the effectiveness of the RT300 functional electrical stimulation (FES) cycling in people 
with spinal cord injuries or patient's condition of paraplegia secondary to myelomenigocele is limited. There is 
insufficient evidence in the literature that supports that the use of the RT300 FES will be effective for your 
condition, or in individuals with quadriplegia  or paraplegia in long term improvement of muscle strength, 
vascular blood flow, bone mineral density, reduction of spasticity and atrophy, facilitation of functional motor 
movement or reduction muscle atrophy in the upper and lower extremities. The requirements listed in the 
Social Security Act, Section 1862 (a)1(A) and the 42 CFR ?411.15(k) for Medicare coverage for the RT300 
FES cycling therapy system have not been 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 the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the RT300 functional electrical stimulator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk in tub. 
 
You asked the Plan to pre-approve the tub. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not serve a primarily medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item 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. Therefore, we 
decided that the Plan does not have to pre-approve a walk in tub.
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 enrollee will have a better chance of full recovery 
and function at home alone with more inpatient therapy. The Plan denied your request. The Plan says criteria 
for admission to the Acute Inpatient Rehabilitation setting have 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 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 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. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. Our physician reviewer also found that 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Lite test strips. 
 
You asked the Plan to pre-approve the strips. You say that you cannot use the One Touch test strips as the 
needles are too big. The Plan denied your request. The Plan says there was no documentation or evidence 
provided indicating that the preferred products on the formulary would not be as effective. 
 
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 strips. 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 medical indication to continue to use Freestyle test strip. 
 
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 strips have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Freestyle Lite test strips.