Persius/hicric huggingface dataset:
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 your mother functioned more independently before 
getting sick and the goal is getting back to return to improving functional mobility. The Plan denied your 
request. The Plan says your mother's records do not show the need for complex daily nursing and rehabilitation 
therapy. 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nail provided on August 24, 2022. 
 
You asked the Plan to pay for debridement of nail. You say that you are requesting reconsideration. 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 debridement of nail 
provided on August 24, 2022.
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 enrollee is not able to manage at home, has a hip 
fracture and continues to fall, intense therapy is needed to get back to the enrollee's normal level. The Plan 
denied your request. The Plan says medically necessary care may be provided safely in a different 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 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 enrollee does not require and is not able to participate in intensive therapy.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the member is receiving appropriate in-patient acute 
care and is currently unstable for transfer to an LTACH. 
 
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 medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee still requires acute care services before transitioning 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty hospital bed rental (E0303). 
 
You asked the Plan to pre-approve this item. You say that the requested item is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of the requested item. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met. Additionally, the beneficiarys weight must be more than 350 
pounds but does not exceed 600 pounds. 
 
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this item have not been met.  Specifically, the record indicates that your weight is less than 350 pounds. Therefore, you do not meet criteria 
for coverage of the requested item. Therefore, we decided that the Plan does not have to pre-approve a heavy 
duty hospital bed rental (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) Mis 
Sensor. 
 
You asked the Plan to pre-approve a Dexcom CGM sensor. You say that the enrollee is blind and needs the 
requested device for her readings. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Dexcom 
CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G6 continuous glucose monitor (CGM) Mis Sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Rebo 2.0 four-wheel power mobility device (PMD). 
 
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 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 patients 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of 
myelodysplastic syndrome (MDS) and bone marrow transplant. The clinical progress note dated April 27, 2022 
indicates he is experiencing intermittent numbness. He is noted to have five out of five strength, normal 
sensation and normal reflexes. Even though the patient has normal motor strength and sensation on physical 
examination, he appears to be a risk for falling and therefore a cane or walker may not be appropriate for his 
mobility needs. However, there is no indication that he cannot propel a manual wheelchair for mobility and accomplishing his daily activities and he is noted to have full motor strength in the upper extremities. If he does 
require a power mobility device, there is a lack of documentation indicating why a standard group 1 power 
mobility device or power scooter would not meet the patients mobility needs versus requiring a 4-wheel power 
scooter. Additionally, there is a lack of documentation indicating that the patients home is accessible for the 
requested four-wheel power mobility device and that he can safely operate it. No power mobility evaluation 
was performed. Therefore, the Rebo 2.0 four-wheel power mobility device 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Rebo 2.0 four-wheel power mobility device (PMD).
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 this stay is medically necessary for you. The Plan 
denied your request. The Plan says a continued SNF stay is not medically necessary. 
 
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 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot talk or swallow, and they do not 
have anyone to assist with their medical needs. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. The 
enrollees care needs 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.  
You asked the Plan to pre-approve HBO therapy. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to specific 
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 HBO therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a diabetic foot ulcer that is now a Wagner I. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not able to walk, balance your own weight at 
all at this time and you are disabled. You want to regain quality of life. The Plan denied your request. The Plan 
says your records show that it is not reasonable to expect that you will be able to safely participate in, or fully 
benefit from, the intensity of services of an IRF, medically necessary care may be provided safely in a different 
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 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 you do not require intensive rehabilitation, unfortunately your functional impairment 
is largely chronic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an intrauterine device (58300). 
 
You asked the Plan to pre-approve insertion of an intrauterine device. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that contraceptive devices or medications are not 
allowed for payment. Based on this information, we decided that Medicare rules for coverage of insertion of an 
intrauterine device have not been met. Therefore, we decided that the Plan does not have to pre-approve 
insertion of an intrauterine device (58300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation to regain strength to 
live independently. The Plan denied your request. The Plan says your records do not show that you need an 
intensive team for your care or therapy for 3 hours a day, medically necessary care may be provided safely in a 
different 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 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 your medical status currently does not require intensive physician and nursing 
oversight 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: 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 acute rehab will improve the enrollee's overall 
function and safety at an ambulatory level with use of their prosthesis. You say the enrollee needs intense 
therapy from multiple disciplines to maximize functional independence with self-care, mobility, transfers, and 
reduce caregiver assist fostering a safe return home. The Plan denied your request. The Plan says the requested 
IRF admission is denied as 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 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 needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 You asked the Plan to pre-approve the compression stockings. You say that you must wear compression socks 
22 hours of 24 hours per day.  You cannot wear regular socks because it causes your legs to swell. You have 
bought several compression socks and they help a little. The Plan denied your request. The Plan says a gradient 
compression stocking is not covered for the treatment of lymphedema in the absence of ulcers. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper 
extremity 
 
You asked the Plan to pre-approve an MRI of the upper extremity. You say that the services are necessary. The 
Plan denied your request. The Plan says 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 the upper extremity. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the record indicates 
that the enrollee had a left shoulder surgery in 2018 and wants to evaluate the right shoulder. The record 
provided does not indicate any symptoms or red flag signs, physical examination findings, or X ray studies to 
support the medical necessity of the requested service.  The requested service is not medically necessary and 
reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time.  The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 the upper extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper extremity