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

 
We decided that the Plan does not have to pre-approve an acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is the best facility available to you, and will do 
the best to get you motivated, and push you to your best. You also say that you need more interaction with the 
physician and staff, and you will get more personal observation. The Plan denied your request. The Plan says 
the IRF admission 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 your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Our reviewer found that you do not require an intensive inpatient rehabilitation therapy 
program. Our physician reviewer also found that based on the medical records provided, there is concern that 
you will not be able to fully participate in and benefit from 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 an acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra.  
 
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 home health physical therapy services. 
 
You asked the Plan to pre-approve 12 home health physical therapy services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 12 home health physical therapy 
services. Our reviewer says that the documentation does not support that the requested home health services are 
medically reasonable or necessary. Our physician reviewer found you required contact guard to stand up and sit 
down, and walking 100 feet times four using a two wheeled walker. The documentation does not support that 
you have documented skilled therapy needs. You are consistently ambulating more than 100 feet with minimal 
supervision. Ongoing home physical therapy is not shown to be medically necessary. Therefore, you do not 
meet criteria for the requested 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 12 home health physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 12 home health physical therapy 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) 
for the enrollee. 
 
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 care can be provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to require additional acute care services for the short term. The 
enrollee does not require services at the proposed LTACH that are not already available at the current facility. 
There are no services at the proposed LTACH that the enrollee requires that is not available and covered at the 
current facility. Therefore, this request for LTACH services will be considered not medically necessary at this 
time. When able, the enrollee can transfer to a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health care services. 
 
You asked the Plan to pre-approve home health care services. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the medical records provided do not show 
that you are currently homebound. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health care services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there are no daily skilled nursing needs. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer. 
 
You asked the Plan to pre-approve these 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. Medicare rules say that Venofer is covered when specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have poor diet. 
There is no evidence that the enrollee is taking oral iron supplements or receiving hemodialysis. As such, the 
documentation does not support that the requested Venofer is medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Venofer.
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. The Plan denied your request. The Plan says the IRF services 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 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 IRF admission is not medically necessary based on lack of medical complexity. Our 
reviewer found that you do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, or an intensive rehabilitation therapy program. Our physician reviewer also found that 
your rehabilitation needs can be met at a lower intensity alternate setting, such as in an SNF or continue in-
home with 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says there are 
not any new clinical problems or changes in circumstances that would require home health care. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found that the enrollee had no pressure ulcers or injuries. There are no incontinence or catheter needs. 
The enrollee requires setup for grooming and dressing. He is at a supervision assist level for bathing, and 
independent for walking using an assistive device. He is able to self-inject prepared medications. The enrollee 
does not have documented skilled nursing or therapy needs. The documentation does not support that home 
health services are medically reasonable and necessary for the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you should not be walking after surgery. The 
Plan denied your request. The Plan says documentation supporting the need for a scooter has not been 
provided. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our physician 
reviewer found that the documentation does not support that you have a mobility limitation that significantly 
impairs your ability to participate in one or more mobility-related activities of daily living (MRADLs) such as 
toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The documentation 
does not support that your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair.  
It has not been documented that you can safely operate the requested device. Therefore, the requested scooter 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 a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trazodone HCL. 
 
You asked the Plan to pre-approve Trazodone. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of your prescription drug plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trazodone HCL.  
 
Benefits for Trazodone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular complete denture. 
 
You asked the Plan to pre-approve the mandibular complete denture. You say that you cannot afford a new 
denture, and you last received a denture in 2016. The Plan denied your request. The Plan says this service is 
allowed one time every 60 months. The Plan also says that you had this service less than 60 months ago. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are limited to one set every 5 
years. The record shows that you received a mandibular denture on February 28, 2016, and your mandibular 
denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular complete denture.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve additional applications of Grafix for the enrollee.

You asked the Plan to pre-approve additional applications. You say that this is medically necessary. The Plan denied your request. The Plan says that a maximum of ten applications is allowed per wound.

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 additional applications. Our reviewer says that the requested additional applications are considered medically reasonable and necessary in this case. Our physician reviewer found additional applications of Grafix PL are necessary to facilitate healing of the foot ulcer.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional applications have been met. Therefore, we decided that the Plan has to pre-approve additional applications of Grafix for the enrollee. 

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 a home ventilator with non-invasive interface (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the MD processed a PP and request clinical be 
resubmitted for this enrollee's denial. The Plan denied your request. The Plan says the records do not support 
the medical necessity for home ventilator with noninvasive interfaces 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the coverage criteria for a home ventilator are not met.  This enrollee has chronic hypoxic and 
hypercarbic respiratory failure due to a combination of severe thoracic restrictive disease and HFpEF.  
Nocturnal respiratory support with BiPAP may be beneficial.  However, Medicare does not cover a home 
ventilator when used as BiPAP.  Certain BiPAP devices are capable of providing the AVAPS-AE mode of 
support that has been ordered.  There is no evidence of failure of BiPAP.  A home ventilator is considered not 
medically necessary, and the denial is upheld. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator with non-invasive interface (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower leg vein ablation. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medical records do not show significant venous insufficiency in the lower legs, 
or skin ulcers with surrounding large superficial varicose veins. 
 
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 procedure. Our reviewer says that 
the requested procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the coverage criteria requires that the symptoms be due to the varicose veins slated for 
treatment. The enrollee has documented recent back issues, with a neurogenic component, and fibromyalgia. 
There is incomplete documentation of lower extremity arterial perfusion in that only femoral pulses are noted. 
There is no documentation of the status of the deep veins or truncal superficial veins. There is documentation 
that there is a potential that the treatments would be merely cosmetic.  There is no documentation of concerted 
efforts at conservative treatment. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lower leg vein ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services rendered on March 
11, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that this is the first time you have been 
billed for these services. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each specialist visit for Medicare-covered benefits.  
 
Review of the file shows that you received specialist services on March 11, 2020. You have been asked to pay 
a $50 copayment for these services. These services fall within the specialist visit for Medicare-covered benefits 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered 
on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and endodontic therapy to be provided by 
an endodontist. 
 
You asked the Plan to pre-approve the consultation and endodontic therapy. You say that you were referred to 
an oral surgeon because of jaw pain. You also say that you need a root canal. The Plan denied your request. 
The Plan says there is no listed benefit for services performed by an endodontist, or for a root canal. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation and endodontic therapy to be provided by an endodontist.