Persius/hicric huggingface dataset:
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 your medical status does not require intensive physician and nursing oversight in an 
IRF. While you may benefit from additional multiple therapies, including physical and occupational therapy, 
the documentation does not reveal that your functional level requires this therapy on an intensive IRF level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continuing oxygen 
therapy, trach care, pulmonary toileting and monitoring of secretions. The enrollee also requires ongoing 
speech therapy for dysphagia and currently is non ambulatory and has significant deconditioning and muscle 
weakness. The Plan denied your request. The Plan says based on Medicare guidelines, the long term acute care 
hospital services you are requesting 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 the enrollee was admitted to the acute care hospital with chronic obstructive 
pulmonary disease exacerbation, pneumothorax with hemothorax, septic shock, acute renal failure, anemia, 
pneumonia and acute respiratory failure requiring mechanical ventilation support, fluids, antibiotics, 
vasopressors, transfusion, and chest tube.  
 A percutaneous endoscopic gastrostomy and trach were placed. Recent notes describe the enrollee as off 
pressors, resolved septic shock, resolved acute kidney injury, and tolerating 10L/m oxygen support via trach 
mask, but with persistent encephalopathy. The enrollee appears to be somewhat unstable but improving and 
should only require short-term additional acute care services that can safely be administered at the current 
facility until more stable and appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lovenox 60/0.6 ml Injections. 
 
You asked the Plan to pre-approve Lovenox. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says the requested drug is for self-administration and is not covered under the Part B 
medical benefit. 
 
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 Lovenox 60/0.6 ml 
Injections.  
 Benefits for Lovenox 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: 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 LTACH is medically necessary. The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs can be 
met at a lower level of care such as a skilled nursing facility (SNF), 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 the enrollee's tracheostomy collar was downsized, and he is tolerating speaking 
valve. The documentation does not support long-term enteral feeding access has been established and is stable. 
The enrollee is receiving appropriate care at the present acute care hospital. 
 
 
 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: 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 a multi-disciplinary 
approach to help manage her medically complex issues. The Plan denied your request. The Plan says the 
criteria for LTACH services have not been met. 
 
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 is no documentation provided indicating medical necessity for admission to a 
LTACH. 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 she is currently receiving 
care. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic bridge (D6245) and a 
porcelain/ceramic retainer crown (D6740). 
 
You asked the Plan to pre-approve a porcelain/ceramic bridge (D6245) and a porcelain/ceramic retainer crown 
(D6740). You say that this is an existing bridge that you have had for 25 years. You also say that the provider 
did not include the information that the Plan needed to ensure that the service would be covered. The Plan 
denied your request. The Plan says this is not medically necessary. The Plan also says that the records did not 
include a reason that the member would not be able to use a removable bridge. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a 
porcelain/ceramic bridge (D6245) and a porcelain/ceramic retainer crown (D6740) when the services are 
medically necessary and reasonable.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a porcelain/ceramic bridge (D6245) and 
a porcelain/ceramic retainer crown (D6740). Our reviewer says that this does not meet criteria. Our physician 
reviewer found the provided x-rays do not clearly show the distal decay, though this may be found clinically. 
Our physician reviewer also found that the rest of the arch is intact or restored with another bridge on the right 
side. Our physician reviewer also found that the supplied documentation does not provide any information that 
supports the notion that a removable appliance could not be worn. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a porcelain/ceramic bridge (D6245) and a porcelain/ceramic retainer crown 
(D6740) have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
porcelain/ceramic bridge (D6245) and a porcelain/ceramic retainer crown (D6740).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) (78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says the requested PET scan is not covered for first staging of the 
enrollee's diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that fluorodeoxyglucose (FDG)-positron emission 
tomography (PET) scan for initial treatment strategy for prostate cancer is not covered. Therefore, we decided 
that the Plan does not have to pre-approve he PET scan. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve 
positron emission tomography (PET) with concurrently acquired computed tomography (CT) (78815).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need further assistance as you cannot stand by 
yourself and are only able to get from the hospital bed to the chair. You also say that you are not mobile and 
have to be carried to the toilet. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about your condition you do not meet the requirements for approval. 
 
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 have functional impairments but there is no specific information to show 
that you can tolerate or require intense therapy. In addition, neurosurgery stated that they do not feel your 
weakness is related to lumbar stenosis thus without a diagnosis for function impairments there is nothing to 
show that a prescribed therapy would result in a significant functional gain. 
 
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: 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 the home ventilator. You say that the home ventilator is medically 
necessary. The Plan denied your request. The Plan says a BiPAP machine meets the enrollee's needs. 
 
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 the home ventilator. Our reviewer says 
that the ventilator is not medically necessary. Our physician reviewer found the 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. 
 
 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 ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 was able to live on her own 
prior to hospitalization. The enrollee now needs oxygen, antibiotics, respiratory therapy, and physical therapy. 
The Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs 
can be met at a lower level of care such as an inpatient rehabilitation facility (IRF), a skilled nursing facility 
(SNF), or at home with home health services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-expiratory positive airway pressure (EPAP) (AE) that could be 
delivered by bilevel positive airway pressure (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 the home ventilator. Our physician 
reviewer found there is no documentation that the ventilator at issue meets Medicare criteria for medically 
necessary and reasonable for you. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered to the enrollee on April 11, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the date of service was reported incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service for clinical laboratory tests 
must be the date that the specimen was collected. 
 
The specimens for these services were collected on March 17, 2022, and March 23, 2022, rather than the billed 
date of service of April 11, 2022. 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 laboratory services 
rendered to the enrollee on April 11, 2022.
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 this member is stable for transfer and 
clearly exceeds the Centers for Medicare and Medicaid Services (CMS) established defining criteria for an 
appropriate LTACH admission. You also say that the member was admitted with shortness of breath and now 
requires LTACH level of care in order to fully recover. The Plan denied your request. The Plan says the 
member is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 3 physical therapy (PT) visits in your home (G0151). 
 
You asked the Plan to pre-approve the home health services. You say that you need these services. The Plan 
denied your request. The Plan says that the requested visits 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 the home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
requested therapy is generally accepted as a specific and effective therapy for your weakness, impaired 
mobility, and increased risk for fall. The reviewer found that the most recent documentation indicated that you 
are independent with mobility and transfers. The reviewer found that you continue to have impaired balance 
and increased risk for falling. Though you are near your baseline level of function, you continue to have 
impaired balance and increased risk for falling. Therefore, the 3 visits of additional home physical therapy can 
be considered 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 the home health services have been met. Therefore, we decided that the Plan has 
to pre-approve 3 physical therapy (PT) visits in your home (G0151).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick urine collection system. 
 
You asked the Plan to pre-approve the urine collection system. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 urine collection system. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no peer-reviewed articles published in the medical literature specific to the 
PureWick system, or external urinary collection system using a continuous low-pressure pump. Thus, there is 
no evidence to show the PureWick system to be an effective alternative in managing urinary incontinence. 
 
 
 
 
 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 urine collection system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a PureWick urine collection system.