Persius/hicric huggingface dataset:
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 enrollee meets the full criteria for the inpatient 
rehabilitation stay. The Plan denied your request. The Plan says the IRF care is not medically necessary, and 
the enrollee's 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 the enrollee was admitted for surgical management of infected artificial knee joint. 
The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. The 
enrollee does 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan can help rule out Alzheimer's and 
frontal lobe dementia. The Plan denied your request. The Plan says a PET scan of the brain is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the requested PET scan is not medically necessary. Our physician reviewer found that there is no indication 
that the enrollee meets the diagnostic criteria for either AD or FTD. 
 
   
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you would like to appeal the denial for $100 
for financial help with utilities. The Plan denied your request. The Plan says the criteria for eligibility have not 
been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee is not a candidate for BiPAP therapy. 
The Plan denied your request. The Plan says advanced capabilities are available on a BiPAP device. 
 
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 ventilator. Our physician reviewer 
found that the enrollee has chronic respiratory failure and obesity hypoventilation syndrome.    The provided documentation does not contain sufficient detailed information to justify the treatment selected. 
The enrollee could be treated with a BiPAP machine. The plan has indicated coverage for such a device is 
available upon request. The elements of the coverage criteria are not satisfied. Therefore, the requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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 services are medically necessary for 
the enrollee's medical needs. The Plan denied your request. The Plan says the enrollee can safely receive this 
care in another setting, such as in their current acute care facility or an outpatient setting if appropriate. 
 
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 they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee 
 
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 pay for inpatient hospital services provided on May 17, 2021, 
through May 22, 2021, and billed with diagnosis code E43. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis E43 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of E43. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code E43-Unspecified protein- 
calorie malnutrition. 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 pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the secondary 
diagnosis of E43-Unspecified protein- calorie malnutrition. Our physician reviewer found that the member was 
treated for anemia, lightheadedness, and acute on chronic kidney injury. The member had lost 10 pounds over 3 
months due to poor oral intake. However, there was conflicting weights entered during the admission, ranging 
from 168 pounds to 200 pounds, both were not directly measured but were reported by the member. During the 
last admission, the member's weight was 178 which would be at the most a 5.6% reduction rather than the 
required greater than 10% reduction in weight. The member's body mass index (BMI) was not low (22.8), there 
was no objective muscle wasting, and there was no specific mention of a reduction in oral intake by at least 50 
percent as required to justify severe protein-deficiency malnutrition. Therefore, diagnosis code E43-
Unspecified protein- calorie malnutrition is not the appropriate secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 17, 2021, through May 22, 2021, and billed with diagnosis 
code E43.
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 are requesting an expedited reconsideration for 
the denial of an IRF admission. You say a lower level of care is not safe, sufficient or equipped to address the 
enrollee's needs related to their comorbidities. The Plan denied your request. The Plan says criteria for 
admission to the IRF setting have not been met. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: 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 necessary for you to receive the 
rehab services needed. The Plan denied your request. The Plan says the services you need can be provided 
safely in another setting. 
 
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 do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 home tests provided on December 30, 2021. 
 
You asked the Plan to pay for the COVID-19 home tests. You say that you should be reimbursed because at the 
time, all of the tests were sold out. The Plan denied your request. The Plan says the service was not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 home tests is an OTC item. Specifically, the COVID-19 tests were purchased prior to the eligibility 
requirements for reimbursement. Therefore, we decided that the Plan does not have to pay for the COVID-19 home tests provided on December 
30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high-frequency chest wall oscillation (HFCWO) 
device. 
 
You asked the Plan to pre-approve HFCWO device. You say that a study shows outcomes improve 
substantially after the initiation of HFCWO therapy. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for this device. 
 
The Plan follows Medicare rules. Medicare rules state that HFCWO devices are only covered if certain criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve HFCWO device. Our reviewer says that 
the enrollee does not meet criteria for this device. Our physician reviewer found the enrollee has a diagnosis of 
chronic obstructive pulmonary disease (COPD) although pulmonary function tests do not show airway 
obstruction. The enrollee has a chronic productive cough. There is no diagnosis of cystic fibrosis, 
bronchiectasis, or neuromuscular disease. There is inadequate evidence of the safety and effectiveness of this 
device in the treatment of COPD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HFCWO device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a high-frequency chest wall oscillation (HFCWO) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft (D4263, D4264). 
 
You asked the Plan to pre-approve bone replacement graft. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary, there is not enough bone loss to allow for 
bone replacement. 
 
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 bone 
replacement graft 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 bone replacement graft. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the documentation provided does not meet the criteria for coverage for bone replacement grafts for retained teeth (D4263, D4264). 
 
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 bone replacement graft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone replacement graft (D4263, D4264).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for post stabilization care provided in Vietnam on August 10, 2022. 
 
You asked the Plan to pay for the post stabilization care. You say that this service was medically necessary and 
should be covered. The Plan denied your request. The Plan says that this service was not emergent and is non-
covered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the post stabilization care. Our reviewer says 
that coverage criteria has been met. Our physician reviewer found the enrollee received hospital care services 
in Vietnam including a coronary stent placement following a heart attack. The enrollee returned for follow-up 
care including an electrocardiogram, lab testing and an examination. The patient could not have foreseen 
requiring the services prior to leaving his service area. The records indicate that the care provided was 
medically necessary as a follow-up for recent emergent procedures and treatments. It would not have been 
reasonable to delay the services until after returning home. 
 
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 post stabilization care have been met. Therefore, we decided that the Plan 
has to pay for post stabilization care provided in Vietnam on August 10, 2022.  
 
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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the member's current medical condition 
requires an LTACH admission. 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 the enrollee appears to be improving with current treatment but is not yet stable for 
transfer and should be able to safely complete treatment at the current facility. The enrollee does not require 
services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is 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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous.  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 LTACH services.