Persius/hicric huggingface dataset:
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 enrollee would benefit from a 
LTACH admission. The Plan denied your request. The Plan says the records do not show that the enrollee 
needs continued treatments and care that can only be given in a hospital 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 is receiving appropriate care at the present acute care setting. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertabral 
nerve (64628). 
 
You asked the Plan to pre-approve the thermal destruction of intraosseous basivertabral nerve. You say that the 
service is medically necessary. The Plan denied your request. The Plan says this service is experimental. 
 
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 thermal destruction of intraosseous 
basivertabral nerve. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided records do not support the medical necessity 
and reasonableness, as defined by Medicare rules, of the requested service for 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 the thermal destruction of intraosseous basivertabral nerve have not been met. Therefore, we decided that the Plan does not have to pre-approve the thermal destruction of intraosseous 
basivertabral nerve (64628).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the removable night guard to treat the temporomandibular joint 
(TMJ). 
 
 
You asked the Plan to pre-approve the night guard. You say that you would like reconsideration because the 
requested night guard is medically necessary. The Plan denied your request. The Plan says that this is excluded 
from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically 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 the night guard. Our reviewer says that 
the documentation meets the criteria in that the treatment of the your TMJ pain is the result of a medical 
condition. Our physician reviewer found the main etiology of bruxism is stress. According to the 
documentation this patient has been diagnosed with Post Traumatic Stress Disorder (PTSD). The treatment 
using a dental splint in this case is to treat the results of a medical condition (PTSD) in alleviation of pain 
associated with TMJ disorder. 
 
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 night guard have been met. Therefore, we decided that the Plan has to pre-
approve the removable night guard to treat the temporomandibular joint (TMJ). 
  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that  The Plan denied your request. The Plan 
says home health services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that home health services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. Provided records do not 
document any acute or unstable medical conditions or changes in medication or treatment which would 
necessitate skilled nursing visits. No medical notes from the enrollees treating physician are provided 
documenting a need for skilled nursing services. Records do not document the need for intravenous 
medications, new tube feeding or ostomy care or daily complex wound 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total shoulder arthroplasty to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve the total shoulder arthroplasty. You say that you tore your rotator cuff again 
and your daily tasks have become very challenging. You say that you would like to be able to see your surgeon 
while you are still in Florida. The Plan denied your request. The Plan says there are contracted providers 
available in the service area. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
  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 total shoulder arthroplasty. Our 
reviewer says that the elements of the coverage criteria are not satisfied, and the requested service is not 
recommended. Our physician reviewer found that the record does not indicate that worsening of the injury was 
foreseeable and does not indicate that the requested surgery is emergent or urgent. The record provided does 
not establish the medical necessity and reasonableness of the requested service for out of network care as 
defined by Medicare 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 the total shoulder arthroplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the total shoulder arthroplasty to be provided by an out-of-network 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care associated with an 
approved reverse approved total shoulder arthroplasty (23472). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee cannot do any more 
physical therapy. The Plan denied your request. The Plan says there is no documentation provided to support 
the expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the reverse approved total shoulder arthroplasty is an elective 
procedure, typically performed at an ambulatory center, and there was no documentation showing an 
expectation for a prolonged post-operative treatment in the hospital. The enrollee was cleared for surgery. 
There was no suggestion that the enrollee would require hospital services that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care associated with an approved reverse 
approved total shoulder arthroplasty (23472).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outdoor scooter and accessories. 
 
You asked the Plan to pre-approve an outdoor scooter and accessories. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says a request for a scooter for outdoor use only 
is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an outdoor scooter and accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging (78815). 
 
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says enrollee does not 
meet the Medicare NCD coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that a 
PET scan is not medically necessary. Our physician reviewer found the record indicates that the enrollee had a 
squamous cell carcinoma of the lip. The record indicates that the enrollee has had surgery and radiation. The 
record does not indicate that the requested test is being used in conjunction with active treatment. The record as 
provided is insufficient to establish whether the coverage criteria are satisfied. 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) for attenuation correction and anatomical localization imaging (78815).
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 LTACH is the appropriate level of care 
for the enrollee. The Plan denied your request. The Plan says under Medicare, the request is not medically 
necessary. 
 
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 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 he is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnish ed safely and effectively only on an inpatient basis. 
 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 dental precision attachments. 
 
You asked the Plan to pre-approve the requested attachment. You say that you cannot eat properly. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental 
precision attachments.
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 daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. You are consistently ambulating more than 100 feet. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your 
care needs, custodial and intermittent, 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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Olmesartan Hydrochlorothiazide (HCTZ). 
 
You asked the Plan to pre-approve Olmesartan HCTZ. You say that the enrollee has high blood pressure. The 
Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part 
B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Olmesartan 
Hydrochlorothiazide (HCTZ).  
 Benefits for Olmesartan HCTZ may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional taxi transportation (A0100). 
 
You asked the Plan to pre-approve the additional taxi transportation. You say that you cannot continue to pay 
for other transportation, as it is $35 each way. The Plan denied your request. The Plan says you have used 14 
trips and have exhausted your benefit. The Plan also says that additional trips are not covered. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 10 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional taxi transportation (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. 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 ventilators are covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that the services are medically necessary. Our physician reviewer found in this case, the record indicates that 
you have chronic respiratory failure from chronic obstructive pulmonary disease. The settings ordered are 
Noninvasive auto-titrating ventilation (AVAPS-AE). The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. You could be 
treated with a bilevel positive airway pressure (BiPAP) machine with Average volume-assured pressure 
support (AVAPS) capability. The plan has indicated such a device is available. 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing visits in your home. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the continued home health services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that the enrollee requires skilled therapy services. Therefore, the 
reviewer found that the requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing visits in your home.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (crutch substitute) coded as E0118. 
 
You asked the Plan to pre-approve the requested knee scooter. You say that you are not able to put any weight 
on your broken foot and need to use the requested knee scooter to get around your house. You feel that this 
should be covered. The Plan denied your request. The Plan says the Plan's medical director finds this item is 
not reasonable and necessary as it has an increased risk of severe injury or death compared to other items. 
 
The Plan must follow Medicare rules. Medicare rules say that the devices coded as E0118 are not considered 
medically reasonable and necessary based on current literature. Therefore, we decided that the Plan does not 
have to pre-approve a knee scooter (crutch substitute) coded as E0118.