Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 service is not medically necessary. Our physician reviewer found there is documentation that you have 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-titration which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in 
the Local Coverage Determination (L33800): Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services. 
 
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 that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Records were neither requested of nor received from the contract home health 
agency, and no other medical records were submitted for review. As such, the health plan has failed to support 
its denial. Therefore, we decided that the Plan has to pre-approve home health services.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from May 27, 2022, to June 4, 
2022. 
 
You asked the Plan to pay for hospital services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says there is insufficient information provided to process this claim. In addition, 
this claim includes both inpatient and outpatient services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 hospital services provided from May 27, 2022, to June 4, 2022. have been met. Specifically, limited medical records were provided for only the date 
of May 27, 2022. Therefore, we decided that the Plan does not have to pay for hospital services provided from 
May 27, 2022, to June 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health skilled nursing visits. 
 
You asked the Plan to pre-approve the home health skilled nursing visits. You say that the services are 
necessary. The Plan denied your request. The Plan says your records do not support the need for a skilled nurse 
to make more visits. 
 
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 the home health skilled nursing visits. 
Our physician reviewer found you do not have documented skilled nursing needs. Lab draws alone are not 
considered an indication for home health skilled nursing visits. As such, the requested, ongoing home health 
skilled nursing services are not medically necessary or reasonable. 
 
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 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the home health skilled nursing visits.
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 cannot walk at this time. You say that you live 
by yourself. You also say that you do not have any help. The Plan denied your request. The Plan says the 
requested admission is 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 the provided documentation does not indicate that you have complex nursing or rehabilitation needs. The reviewer found that while you have a need for therapy, there is no documentation of a 
need for an intensive rehabilitation program. The reviewer also found that there is not a reasonable expectation 
that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Therefore, the reviewer found that the requested IRF admission is not medically reasonable 
or 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.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brovana. 
 
You asked the Plan to pre-approve Brovana. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Brovana. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drug. There is no documentation provided indicating that the plans required drug would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Brovana.
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 you have not been out of bed in 2.5 years. You say 
that you want to get the therapy so you can get out of bed. You also say that the only way you will be strong 
enough to get out of bed is if you get inpatient therapy at a Skilled Nursing Facility. The Plan denied your 
request. The Plan says no daily skills have been ordered by a physician. 
 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 documentation does not support that you have daily skilled nursing needs that 
required the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily 
skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychosocial rehabilitation services and targeted case 
management. 
 
You asked the Plan to pre-approve psychosocial rehabilitation services and targeted case management. You say 
that psychosocial rehabilitation services and targeted case management is medically necessary. The Plan denied 
your request. The Plan says psychosocial rehabilitation services and targeted case management is 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 psychosocial rehabilitation services and 
targeted case management. Our reviewer says that psychosocial rehabilitation services and targeted case 
management is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that based on review the records provided, it is noted that you have depressive symptomatology but you are 
able to perform activities of daily living other than notifications from financial, government and medical 
providers. You do not have any suicidal or homicidal thoughts and do not require inpatient care for 
psychosocial rehabilitation services and targeted case management. Based on review the records provided you do not require care for the treatment utilizing psychosocial rehabilitation services and targeted case 
management but you could be treated on an outpatient basis by your doctor along with therapy and therefore is 
not considered 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 psychosocial rehabilitation services and targeted case management have not 
been met. Therefore, we decided that the Plan does not have to pre-approve psychosocial rehabilitation services 
and targeted case management.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a lack of pertinent supporting information. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided, there is no documentation that the patient 
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. The 
records do not document the need for intravenous medications, new tube feeding or ostomy care or daily 
complex wound care or respiratory care. There is inadequate documentation to clarify that daily skilled services 
are required. The patient is reported to be "requiring some help, but able to walk without assistance." No details 
are provided with regard to the distance she can walk or her assistance level for transfers or activities of daily 
living. Although records document the patient is limited functionally, provided records do not clarify a 
significant decline in the patients functional status compared to her recent baseline to necessitate daily 
inpatient skilled therapy services. The records do not support that services in the home or an assisted living 
facility with home health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
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 admission to a skilled nursing facility (SNF) for the enrollee.
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 the enrollee would benefit from inpatient rehab to 
improve overall functional mobility and safety prior to returning home. You also say that an IRF admission 
would reduce the caregiver burden and risk of readmission to an acute care facility. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies at an intensive rehabilitation therapy program. The 
enrollee can receive further services 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnosis interview examination provided on 
January 12, 2022. 
 
You asked the Plan to pay for the psychiatric diagnosis interview examination. The Plan denied your request. 
The Plan says the member had elected hospice on this date of service. 
 
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 a psychiatric diagnosis interview examination provided on 
January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Device (CCM). 
 
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 while the Optimizer Smart Device was 
approved by the Food and Drug Administration (FDA) in 2019, it remains the subject of multiple studies 
examining long-term effectiveness and clinical trials to quantify effectiveness. It is premuature, at this time, to 
presume clinical outcomes and benefit of the device. 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 an Optimizer Smart Device (CCM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 continued 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 need skilled nursing or skilled therapy services 
(or a combination of these services) on a daily basis. The enrollee does not require the necessary services on an 
inpatient basis, in a skilled nursing facility setting. The enrollee is at a level of function which can improve 
with repetitive exercise without daily skilled 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
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 SNF care is medically necessary. The Plan 
denied your request. The Plan says the SNF care is not medically necessary, and the enrollee's needs can be met 
at a lower level of care such as at home, in a long-term care facility, or other 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 the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. It is not clear that the enrollee has had an acute decline in function, or 
that she can actively participate in skilled therapy. Daily skilled services are not shown to be required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care (ex. home, 
assisted living, long-term care). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.