Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that the enrollee has to be inpatient 
because she has no help at home. The Plan denied your request. The Plan says that 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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The enrollee is 
undergoing a planned total hip arthroplasty.  The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. 
The planned procedure is not listed on the Inpatient Only List. The procedure is currently approved as an 
ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require 
a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting 
physician would reasonably expect that the patient's necessary hospital care would span two midnights. Our 
physician reviewer found that the enrollee's condition does not meet criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show that it is safe to leave the hospital at this time, 
given severe brain problems, which is interfering with long-term weaning. 
 
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 appears to be improving and should only require short-term additional 
acute care services that can safely be administered at the current facility including weaning. The enrollee does 
not require services at the LTACH that are not already available at the current facility. Transfer to LTACH is 
not medically necessary as it would not be clinically advantageous. Transfer may be considered when treatment 
has completed. 
 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve the continued inpatient psychiatric hospitalization. The Plan denied your 
request. The Plan says the clinical information shows that the enrollee has stabilized as much as possible in an 
acute inpatient setting and continued care at a lower level of care is more appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
  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 continued inpatient psychiatric 
hospitalization. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient 
psychiatric care beyond March 8, 2022. Our physician reviewer found that it is not expected that the enrollee 
will improve in a reasonable period of time beyond the date in question as the enrollee was not showing any 
dangerousness to self or others, auditory or visual hallucinations, or aggressive behaviors. The enrollee was 
cooperative and compliant with medication. It does not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continued inpatient psychiatric hospitalization have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continued inpatient psychiatric 
hospitalization.
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 appears to be somewhat unstable and requires additional short-term acute 
care services that can safely be administered at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to LTACH would 
not be clinically advantageous as the enrollee is not yet stable enough.  
 
 
 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: 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 and skilled therapy needs. Daily skilled services are not shown to be 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. The 
enrollee's rehab needs can be met at a lower intensity and alternate setting such as in a skilled nursing facility 
or in the assisted living facility with 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on February 24, 2022 for drainage of an incision site. She continues to work with therapy to improve 
functional abilities. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She does not require treatment 
by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have low 
back pain radiating to your legs. The requested Minuteman procedure is considered experimental in nature, as 
more research is needed to show its effectiveness. The services are therefore 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 Minuteman procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lesion removal surgery. 
 
You asked the Plan to pre-approve lesion removal surgery. You say that the surgery is necessary for a life-
threatening condition. The Plan denied your request. The Plan says the criteria for coverage have not been met, 
and this procedure would be considered cosmetic in nature. 
 
The Plan follows Medicare rules. Medicare rules say that the indications for coverage of skin lesions is listed 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 lesion removal surgery. Our reviewer 
says that the requested surgery services are not medically reasonable and necessary. Our physician reviewer 
found that the record indicates that the enrollee has mastocytosis on the arms, lip, neck, nose, and trunk. The 
record does not document the presence of any enumerated criteria in the local coverage determination for the 
removal of benign lesions. The elements of the coverage rules 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 lesion removal surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lesion removal surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on  
October 21, 2021. 
 
You asked the Plan to pay an additional amount for eyeglasses. You say you are entitled to the eyewear benefit. 
The Plan denied your request. The Plan says the maximum eyewear allowance of $150 was paid. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum eyewear 
allowance of $150. Therefore, we decided that the Plan does not have to pay an additional amount for 
eyeglasses provided on October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as an acute 
rehabilitation facility, nursing facility, outpatient setting, or home care. 
 
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 you appear to be improving and should require only short-term additional acute care 
services that can safely be administered at the current facility. You do not require services at the LTACH that 
are not already available at the current facility. Transfer to LTACH is not medically necessary as it would not 
be clinically advantageous. Transfer to a lower level of care may be considered. 
 
 
 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 admission to a long-term acute care hospital (LTACH).
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 enrollee met their 
therapy goals by March 8, 2022 and no longer needed to have more inpatient rehabilitation. 
 
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 an IRF stay is not medically necessary based on lack of documented medical 
complexity, lack of acute rehab nursing needs (absent records) and documented physical therapy progress. Our 
reviewer also found that the documentation does not support the necessity for an IRF extension beyond March 
8, 2022. 
 
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 power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee's wheelchair is no longer 
appropriate. The Plan denied your request. The Plan says medical equipment must be for use in the home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
We looked at the file and the rules. The records show that a power wheelchair is being requested for use in a 
SNF or hospital. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested scan. You say that the enrollee needs the test to evaluate for 
abnormalities. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 We looked at the file and the Medicare rules. We find that the enrollee does not meet the age requirement for 
the requested test. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography 
(LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to 
the enrollee on June 28, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat 
peripheral artery disease is not eligible for reimbursement. 
 
The requested device (E0675) and accessory (E0673) are statutorily not covered by Medicare. 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 pay for a pneumatic compression device (E0673, E0675) provided to the 
enrollee on June 28, 2021.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on March 1, 2022. The therapy notes dated March 9, 2022 state she needs modified assist for sitting up 
and taking eight side steps and maximal assist to stand up. She does not require the intensity of services in an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, 15 hours per week of 
rehabilitative services and regular physician evaluation. 
 
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.