Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve the continuation of care with an OON provider. You say that the in-network 
options you contacted were unacceptable. You say that your condition is worsening every day and that your 
existing doctors know the context of your illness. You say that going to a new provider will restart all of your 
progress and it will take too long to get an appointment. The Plan denied your request. The Plan says there are 
in-network providers who can provide the services you need within a timely manner. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a continuation of care with an out of 
network (OON) provider. have been met. Specifically, there were no medical records provided to demonstrate that it is medically necessary to continue care with an OON provider. The Plan provided evidence that they 
made reasonable attempts to obtain medical records. Without this documentation, we are unable to make a 
determination regarding medical necessity.  Therefore, we decided that the Plan does not have to pre-approve a 
continuation of care with an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71260). 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the medical records submitted show 
medical necessity for a CT scan of the chest. The Plan denied your request. The Plan says the enrollee does not 
meet Chest CT scan guidelines. 
 
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 a CT scan of the chest. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee recently had pneumonia and is clinically doing well. The provided record does not support the medical 
necessity of the requested service at this time. The provided records do not indicate the medical necessity or 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. 
 
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 CT scan of the chest have not been met.  
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
chest (71260).
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 currently meets the IRF admission 
criteria. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has multiple active comorbidities and would benefit from close medical 
supervision. However, evaluating therapists document that the enrollee may be close to functional baseline and 
recommend less intense therapy in a skilled nursing facility. Our reviewer also found that the enrollee would 
not be expected to tolerate intensive rehabilitation and IRF criteria 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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 a home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The medical 
records provided state she requires standard BiPAP. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Artacent skin substitute. 
 
You asked the Plan to pre-approve Artacent skin substitute. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Artacent skin substitute. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is insufficient evidence in the medical literature to support the use of this 
skin substitute product in this setting. There is a lack of demonstrated efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Artacent skin substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Artacent skin substitute.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 was admitted with bleeding perforated ulcer and required operative 
intervention. The record indicates that the enrollee is improving but still require acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH facility. 
 
 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 the ROMTech PortableConnect device and accessories. 
 
You asked the Plan to pre-approve the ROMTech PortableConnect device. You say that this device is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested 
device is considered experimental/investigational. 
 
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 ROMTech PortableConnect device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is insufficient evidence in the literature on the safety, 
effectiveness, and health outcomes from the use of this device. 
 
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 ROMTech PortableConnect device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the ROMTech PortableConnect device and accessories.
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's current physical and occupational 
deficits, along with her comorbidities, support the need for intensive inpatient rehabilitation hospitalization 
with daily physician visits and examinations, 24-hour rehabilitation nursing care, and intensive therapies. The 
Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the 
enrollee can safely receive the services needed in other settings. 
 
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 does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee has a history of pelvic fracture in May 2022 and is living at home after acute 
care and skilled nursing care stays. There is ongoing weakness. The enrollee's medical problems are stable. 
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 supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care, daily complex wound care or respiratory care. There 
is no documentation that daily skilled services are required. Although records document you are very limited 
functionally, provided records do not document a significant decline in your functional status compared to your 
recent baseline to necessitate daily inpatient skilled therapy services. You do not require the services on an 
inpatient basis, only in a skilled nursing facility setting. Records do not document that services in the home 
with home health care or in a long-term care facility on a part time basis are not 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device. 
 
You asked the Plan to pre-approve a continuous passive motion device. You say that this device should be 
covered for your condition. The Plan denied your request. The Plan says this device is not covered by Medicare 
when used for your shoulder injury. 
 
The Plan must follow Medicare rules. Medicare rules say that a continuous passive motion device will be 
covered for patients who have received a total knee replacement. There is insufficient evidence to justify 
coverage of these devices for longer periods of time or for other applications. 
 
We looked at the file and Medicare rules. In this case, you are requesting this device following a shoulder 
surgery, not a total knee replacement as required by Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continuous passive motion device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous passive motion device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve Truxima. 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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Truxima. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 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 Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the enrollee struggles with 
chronic back pain and shortness of breath on exertion. You say that the oxygen tanks are too heavy for the 
enrollee to carry around. The Plan denied your request. The Plan says the records provided do not indicate that 
the portable oxygen tanks provided to the enrollee are not meeting his needs for portable oxygen. The Plans 
says that, because the enrollee has not tried and failed portable oxygen tanks, the request for an authorization 
for a portable oxygen concentrator has been denied. 
 
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 a portable oxygen concentrator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a portable 
oxygen concentrator is not medically necessary.  This enrollee has portable oxygen tanks but has not tried 
lighter tanks or liquid oxygen system that are available to him.  Also, there is no testing to demonstrate that he 
is able to maintain a blood oxygen saturation level (SpO2) greater than 91% while exercising using an oxygen 
conserving device with flow rate 1 to 4 liters per minute. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #14. 
 
You asked the Plan to pre-approve a crown for tooth #14. You say that your tooth broke off and is missing half 
of its mass. You also say your dentist said it is large enough that they cannot fill it with a post and filling. The 
Plan denied your request. The Plan says that the tooth does not appear to have significant breakdown. 
 
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. The Plan covers a crown for 
tooth #14 when the services are medically necessary and reasonable. 
 
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 crown for tooth #14. Our reviewer 
says that the documentation provided meets the criteria for coverage for a crown restoration for tooth #14. Our 
physician reviewer found the documentation indicates that a core buildup has been approved. Our reviewer also 
found that the placement of a crown restoration is medically reasonable and necessary to return the tooth to 
adequate masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown for tooth #14 have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2740) for tooth #14.  
 
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: 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. The Plan denied your request. The Plan says the clinical 
information provided does not support the medical necessity of care in an acute inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our reviewer also found that there is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain your functional status. 
 
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.