Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport provided on September 22, 2022. 
 
You asked the Plan to pay for the ambulance service, advanced life support, emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says based on the information received the claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that this includes all items and non-physician services 
furnished to inpatients must be furnished directly by the hospital or billed through the hospital under 
arrangements. This includes transportation  including transportation by ambulance  to and from another 
hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the 
facility where the patient is an inpatient. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance service, advanced life support, emergency transport have not been met.  
Therefore, we decided that the Plan does not have to pay for the ambulance service, advanced life support, 
emergency transport provided on September 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca (Q5111). 
 
You asked the Plan to pre-approve Udenyca. The Plan denied your request. The Plan says despite multiple 
attempts, medical records were not received by the provider. The Plan also says a phone conversation with the 
provider confirmed that the enrollee had not tried the preferred drugs, Ziextenzo and Fulphila, and that the 
enrollee had no contraindications to the preferred drugs. 
 
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 Udenyca have been met. Medical 
records were not provided for this case. The record shows that the Plan made multiple attempts to obtain this 
information, but it was not received. Without medical records, we are unable to determine if the enrollee meets 
the criteria for coverage for Udenyca. Therefore, we decided that the Plan does not have to pre-approve 
Udenyca (Q5111).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee medical needs are not 
suitable for a lower level of care. You say that the enrollee is stable and suitable for transfer to an LTACH. You 
say that the enrollee can be adequately cared for in an LTACH. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee can get the services they need in another 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has ongoing acute medical issues and still requires acute care 
services. The enrollee's acute care services have not been denied. The medical record does not indicate that the 
enrollee requires services that they are 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 LTACH 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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. Daily skilled services are not 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. 
 
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: 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 the requested 
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 the requested home ventilator. Our physician reviewer found the 
enrollee was recently hospitalized with COVID-19 and H influenza pneumonia.  There is a history of chronic 
obstructive pulmonary disease (COPD). However, there are no pulmonary function tests to confirm the 
diagnosis of COPD or assess severity. There is no arterial blood gas, done while stable, demonstrating CO2 retention. This enrollee does not meet criteria for ventilatory support during sleep as an outpatient. If the 
enrollee does have severe COPD with chronic CO2 retention, they may benefit from BiPAP with AVAPS 
during sleep. Medicare does not cover a home ventilator when used as BiPAP. 
 
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: 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 you feel you are not receiving proper 
care at the current facility. The Plan denied your request. The Plan says the records do not show that it is 
medically necessary to be in an LTACH in place of an acute care 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 that the patient appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be provided at the current facility until more 
appropriate for a lower level of care. It is not clear if the patient is able or not to wean. The patient does not 
require services at the LTACH that are not already available at the current facility. There are no services at 
the LTACH that the patient requires that are not already available and covered at the current facility. Transfer 
to the LTACH is not medically necessary as it would not be clinically advantageous. Completion of treatment 
at the current facility is 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant on tooth #13 (D6010), a 
prefabricated abutment on tooth #13 (D6056), an abutment supported crown on tooth #13 (D6058), a pontic on 
tooth #12 (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary. The Plan denied your request. The Plan says that enrollee must have at least eight permanent teeth 
that bite together. 
 
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 the dental 
services 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 the dental services. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that a review of the documentation indicates that the enrollee is missing maxillary posterior teeth bilaterally. Other means of replacing missing 
posterior teeth can be utilized to achieve better bilateral masticatory function. An implant and an attached 
pontic are not medically reasonable and necessary to achieve good 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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an endosteal implant on tooth #13 (D6010), a prefabricated abutment on tooth #13 
(D6056), an abutment supported crown on tooth #13 (D6058), a pontic on tooth #12 (D6245).
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 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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
with a lung abscess and pneumonia. She has presumed obesity hypoventilation syndrome and obstructive sleep 
apnea (OSA). The records do not support a diagnosis of chronic obstructive pulmonary disease (COPD). There 
is no diagnosis of thoracic restrictive disease or neuromuscular disease. There is no documented arterial blood 
gas (ABG) done while stable as an outpatient. Medicare does not cover a home ventilator when used as bi-level positive airway pressure (BiPAP), or for the diagnosis of obesity hypoventilation syndrome. The home 
ventilator is not reasonable or 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 home ventilator.
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 get the care they need at home. 
You say that it is best for the enrollee to be in a SNF. The Plan denied your request. The Plan says a SNF 
admission is not medically necessary, and the enrollee's need can be met in an outpatient setting. 
 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 or skilled therapy on an inpatient basis in a 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a push-rim activated power assist system (E0986). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary as a separate device 
that is added to the wheelchair when needed. The Plan denied your request. The Plan says that an expert 
recommended an ultralightweight manual wheelchair instead. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that you have sickle cell disease and paraplegia secondary to a thoracic level spinal cord injury. You are 
unable to ambulate and requires a manual wheelchair for mobility and accomplishing daily activities. You are 
noted to have decreased strength in the upper extremities and fatigues when propelling your manual wheelchair 
community distances. You would benefit from a push-rim power assist system to be able to propel the manual 
wheelchair community distances. Given the paraplegia, you are also at risk for shoulder injuries, and this will 
allow preservation of shoulder function. A specialty evaluation was performed by physical 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve a push-rim activated power assist system (E0986).  
 
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 pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested care is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested care 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 the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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: 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 you wish to return being independent as quickly as 
possible. You say that you can participate and complete the required 3 hours of therapy that you cannot get in a 
nursing home. You say that your goal is to return home. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and your needs can be met at a lower 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 that you do not require the intensity of services provided at an IRF.  Specifically, you 
do not require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for LTACH services. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 LTACH services.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 you were admitted to the hospital on January 6, 2023 after a fall from your 
wheelchair. You received physical and occupational therapy in the hospital. The records do not support that 
you require the intensity of services provided in an IRF. Specifically, you are not showing to need 15 hours per week of rehabilitative services and regular physician evaluation. The IRF services are not reasonable or 
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 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.