Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an emergency room visit provided on May 16, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were admitted to 
the hospital and that the emergency room visit was justified. The Plan denied your request. The Plan says that 
the copayment applied was correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records with evidence that you were not 
admitted to the hospital. Therefore, we decided that the Plan has to waive the copayment for an emergency 
room visit provided on May 16, 2022.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the enrollee requires 
additional visits due to not having full lower extremity strength at this time. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 10 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the enrollee has previously been treated 
with outpatient therapies and should be independent with a home exercise program. There is no documentation 
of a recent injury or decline in function. The additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient service provided on June 6th, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers. You say that you think the billing was processed 
incorrectly. The Plan denied your request. The Plan says this cost sharing was charged 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 $275 
copayment for Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay $275 copayment for outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers. This item/service falls within the Medicare-covered 
outpatient hospital facility visit 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 
outpatient service provided on June 6th, 2022.
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 SNF care is medically necessary for rehabilitation. 
The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF coverage 
under the Medicare Part A benefit. 
 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 based on the documentation provided, the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs are 
custodial and can, as a practical matter, be provided at a lower level of care  
(ex. home, assisted living, long term 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 25, 2022, 
through May 24, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says an NOA was not submitted. As such, the claim cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs must submit an NOA at the beginning of a 
home health admission. 
 
We looked at the file and Medicare rules. The Plan has indicated that no NOA was received from the provider. 
The provider has not submitted clear evidence to support that an NOA was sent to the Plan. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from April 25, 
2022, through May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical need for the single power option included with K0856 group 3 
power wheelchair. 
 
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 the services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder that would necessitate power tilt or recline. The medical necessity for the 
specifically requested power wheelchair is not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. The Plan denied your request. The Plan says that says 
the medical records do not support a continued stay at a skilled nursing facility. 
 
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 continued SNF care. Our reviewer says 
that the requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. 
Our physician reviewer found the enrollee receives twice daily wound care and continues enteral feeding. The 
enrollee does not have documented skilled therapy needs. The enrollee is dependent and unable to participate in 
skilled therapy. The enrollee is consistently ambulating more than one hundred feet and tending to activities of 
daily living skills with minimal support. It is determined that daily skilled services are required to prevent 
deterioration of the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have been met. The Plan must continue coverage for the 
SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been 
issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve 
continued SNF care.  
 
 
 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 16, 
2022, to May 15, 2022. 
 
You asked the Plan to pay for SNF care. You say that SNF care continued to be medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for continued SNF 
care were not met.  
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 pay for 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 had reached a level of function routinely managed at a home care level. 
She was able to improve with repetitive exercise and support from non-skilled personnel. She did not require 
daily input from skilled therapists as required by Medicare coverage rules. 
 
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 pay for skilled nursing facility (SNF) care provided from April 16, 2022, to May 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart implantable pulse generator for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies haven't proven that the device is helpful for treatment of the health 
problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is whether implantation of the cardiac contraction motility (CCM) system in this patient is 
medically necessary for the treatment of congestive heart failure (CHF) which has been deemed refractory to 
optimal medical therapy. An exhaustive review of the current medical literature pertaining to the CCM system 
confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical 
trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple 
studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to Food and Drug Administration (FDA) approval in 2019, CCM 
remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, 
double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is 
premature to presume clinical outcomes and benefit. This request would be considered to be not medically 
necessary for this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Optimizer Smart implantable pulse generator for the enrollee.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance image guided high intensity 
focused ultrasound (MRgFUS). 
 
You asked the Plan to pre-approve MRgFUS. 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 MRgFUS) unilateral thalamotomy is considered 
medically reasonable and necessary in patients who meet specific criteria. 
 
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 MRgFUS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case the enrollee was offered deep 
brain stimulation (DBS) as a treatment option for their essential tremor. However, the enrollee opted to decline 
this treatment. The elective refusal of DBS would not satisfy the requirement that a patient has failed DBS or is 
not able to tolerate the procedure due to other medical problems. The enrollee is noted to have a history of 
blood clots (PE) for which they are/have been on warfarin. This would present as a risk factor for deep vein 
thrombosis (DVTs) and there is the possibility of an underlying Coagulopathy (there was not sufficient history 
provided to permit a conclusion if a coagulopathy had been diagnosed in the past). Given these factors, it 
cannot be said that the beneficiary meets criteria for coverage based on the information provided for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRgFUS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance image guided high intensity focused ultrasound (MRgFUS).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral neuromodulation (64581, 64590). 
 
You asked the Plan to pre-approve sacral neuromodulation. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 sacral neuromodulation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found sacral neuromodulation is not medically reasonable and necessary in this case. The 
records do not show that the enrollee has met the criteria needed for coverage. Specifically, the records do not 
show that enrollee has at least 2 episodes of fecal incontinence per week, has failed conservative therapy, has 
had an evaluation to rule out other treatable diseases and does not have any exclusionary conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacral neuromodulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacral neuromodulation (64581, 64590).
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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care 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 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 is a 72-year-old with a history of diabetes mellitus and spinal stenosis. 
Based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. The enrollees care needs can be met 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 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 SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would benefit from continued therapy. The Plan 
denied your request. The Plan says at your current level of function, daily physical and occupational therapy is 
not medically necessary. Your needs can be met with intermittent physical and occupational three to four times 
per week. 
 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 are at a contact guard to minimal assist level with functional mobility gait to 
sixty feet. You required varying assist with activities of daily living skills. 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. Our reviewer also found 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 SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve home health skilled nursing services. You say that you need continued 
services for wound care, observation, and assessment of disease process. The Plan denied your request. The 
Plan says you do not require additional skilled nursing services. 
 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 skilled nursing services. 
Our reviewer says that home health skilled nursing services are not medically necessary. Our physician 
reviewer found the clinical documentation states that your wounds are healing and there is no change in status 
or concerning findings with routine wound care. There is no documentation to support continued home health 
skilled nursing 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 home health skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health skilled nursing services.