Persius/hicric huggingface dataset:
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 it is not safe for the enrollee to discharge home as 
they have already failed at that. 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 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 daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does 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 and 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 skilled nursing facility (SNF) care.
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 requires continued complex 
wound care, multispecialty physician follow-up, daily labs and therapy services. The Plan denied your request. 
The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 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. The health 
plan has approved ongoing care in the current acute care 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four home health occupational therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the 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 services are not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled rehabilitation services to 
effectively provide treatment, care, and/or services to improve their condition, perform a maintenance program 
to maintain their condition and/or prevent deterioration. The enrollee has been medically stable without any 
recent exacerbations of chronic medical problems or hospitalizations. 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 four home health occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 7, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110).
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 patient is being treated for chronic 
respiratory failure following progressive chronic obstructive pulmonary disease (COPD). The Plan denied your 
request. The Plan says a home ventilator is not medically necessary for this patient. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the enrollee is an 80-year-old 
female with past medical history of COPD. The records sent indicate that she was recently admitted to the 
hospital in March to April of 2023 because of chronic hypercarbic and hypoxic respiratory failure. The arterial 
blood gas (ABG) showed a CO2 level of 55.2 on March 2, 2023. She had pulmonary function testing on 
November 24, 2021, which showed moderate to severe obstruction. She was treated during her hospital stay 
with bilevel positive airway pressure (BiPAP) therapy during the hospital stay. Her provider says she needs a 
ventilator for Average Volume Assured Pressure Support therapy mode (AVAPS), which can be delivered by 
bilevel PAP machine with AVAPS capability. The records we received do not tell us if she was treated with 
BiPAP during the hospital stay, or if she was treated with BiPAP with AVAPS. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on December 28, 2022, 
through December 30, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services were medically necessary, 
and it is incorrect to deny payment. The Plan denied your request. The Plan says the services are not covered 
under 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 pay for the self-administered drugs 
received on December 28, 2022, through December 30, 2022.  
 
Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair. 
 
You asked the Plan to pre-approve a heavy-duty manual wheelchair. You say that you only fall two pounds 
short of the Medicare guideline, and you need this chair due to your size. The Plan denied your request. The 
Plan says you do not meet criteria for this item because you do not meet Medicare weight requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty wheelchair is covered if you weigh 
more than 250 pounds or have severe spasticity. In this case, the records do not document that you have severe 
spasticity.  Further, the records show that your current weight is 248 pounds, so you do not meet the weight 
criteria for coverage of this item under Medicare rules. We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of a heavy-duty manual wheelchair have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve selective arterial catheter placement for the treatment of aneurysm. 
 
You asked the Plan to pre-approve selective arterial catheter placement for the treatment of aneurysm. You say 
that this is a life-threatening matter and this needs to be approved. The Plan denied your request. The Plan says 
that selective arterial catheter placement for the treatment of aneurysm is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 selective arterial catheter placement for 
the treatment of aneurysm. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found you have an extremely complex condition 
requiring expert care. It is anticipated that you are to undergo endograft repair of your perivisceral aneurysm 
using a fenestrated device. The plan will likely involve covering the celiac artery. The diagnostic angiogram at 
issue for this review is required to determine that it would be safe to do so. There are no set criteria that would 
apply to this circumstance.  However, on review of the information provided, there is ample documentation 
(including a computed tomography angiography image) all supportive of the medical necessity of the treatment 
in question.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective arterial catheter placement for the treatment of aneurysm have been 
met. Therefore, we decided that the Plan has to pre-approve selective arterial catheter placement for the 
treatment of aneurysm.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of the bone and debridement of the muscle 
and fascia Provided on September 16, 2022. 
 
You asked the Plan to pay for the debridement of the bone and debridement of the muscle and fascia. You say 
that the claim needs to be reprocessed. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the debridement of the bone and debridement of the muscle 
and fascia Provided on September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network chiropractic services 
provided on December 01, 2022. 
 
You asked the Plan to waive the copayment for out-of-network chiropractic services. You say that you disagree 
with the copayment. 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 a $65 
copayment for out-of-network chiropractic services. 
 
You have been asked to pay a $65 copayment for out-of-network chiropractic services. This item/service falls 
within the out-of-network chiropractic services 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 out-of-network chiropractic services provided on December 01, 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 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 require skilled nursing or therapy services on a daily basis. The 
enrollee does not meet severity of illness or intensity of service criteria for 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need more therapy and rehabilitation to gain 
more strength to be home alone. You say you do not feel comfortable going home due to the risk of falls. The 
Plan denied your request. The Plan says the IRF care is not medically necessary, and your needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted for infection of the foot and a below the knee amputation. Your 
medical problems are stable, and there are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the patient requires a ventilator so he can 
breath and a bilevel positive airway pressure (BiPAP) device will not work for his condition. The Plan denied 
your request. The Plan says the medical records do not show failure with BiPAP, so the requested ventilator is 
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 a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found This patient has a diagnosis of 
chronic obstructive pulmonary disease (COPD) as well as obstructive sleep apnea and was previously 
intolerant of continuous positive airway pressure (CPAP).  The patient was recently hospitalized with acute 
respiratory failure, requiring intubation because of agitation.  Their arterial blood gas (ABG) was consistent 
with acute on chronic hypercarbic respiratory failure. A chest computed tomography scan showed debris and 
occlusion of the airways suggestive of acute aspiration. The patient improved and was discharged without any 
need for supplemental oxygen. There are no pulmonary function tests to confirm the severity of the 
COPD.  There is no ABG done while stable to document chronic carbon dioxide (CO2) retention.  If this 
patient does have chronic CO2 retention, they may benefit from BiPAP with average volume-assured pressure 
support (AVAPS) during sleep.  Medicare does not cover a home ventilator when used at settings that can be 
provided with 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for your care 
needs. The Plan denied your request. The Plan says the t your needs may be met at an alternative 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 IRF admission is not medically necessary based on lack of medical complexity. 
While you may benefit form physical and occupational therapy, your therapy needs can be provided safely in a 
low intensity alternate setting such as in a skilled nursing 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a CT 
scan provided on September 7, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and a CT scan. You say that 
you should not have a cost share for services that were authorized by the Plan. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $300 copayment for Medicare-covered diagnostic 
radiology services.  
 
You have been asked to pay a total cost share of $301.92. The total includes a $1.92 coinsurance for Medicare 
Part B prescription drugs ($9.60 allowed x 20% = $1.92) and a $300 copayment for a CT scan. The Medicare 
Part B prescription drug falls within the Medicare Part B prescription drugs benefit category. The CT scan falls 
within the outpatient diagnostic tests 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 cost share for 
Medicare Part B prescription drugs and a CT scan provided on September 7, 2022.