Persius/hicric huggingface dataset:
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 the enrollee would benefit from LTACH 
services due to dropping hemoglobin, a recent tracheostomy procedure, not tolerating the tracheostomy collar 
overnight, and the need for airway monitoring. The Plan denied your request. The Plan says the enrollee does 
not meet the requirements for admission 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 that all medically necessary care is being provided in the current acute care setting.  
 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 Plan. The Plan has approved ongoing care in the current acute care setting. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (99204) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a consultation. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there are in-network providers that can perform this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a consultation (99204) to be provided by an out-of-network (OON) provider.
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 require physical and occupational therapy to 
help gain your strength. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met in other settings. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary, and the enrollee's needs can be met at a lower level of care. 
 
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 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 not 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 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor (E0652) to be provided by an out-of-network (OON) provider.
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 further delay in transition of care will impact their 
ability to regain medical and functional well-being. 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 has reduced ability to participate in or tolerate intensive therapy. The 
enrollee has chronic functional loss and is primarily deconditioned. The enrollee does not require intensive 
rehabilitation or frequent physiatry oversight.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 as they have already tried and failed vent weaning attempts. The Plan denied your request. The 
Plan says your care can be provided in the current inpatient hospital. 
 
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 presently receiving appropriate services in the acute care setting. 
Records indicate the long-term acute care is needed for weaning, chest tube management, telemetry, laboratory 
monitoring and physical, occupational and speech therapy. The weaning, chest tube management, telemetry 
and laboratory monitoring can be provided in the current hospital setting. There are no notes from physical, 
occupational or speech therapy that have been provided indicating the enrollee is able to participate and benefit 
from such treatment given. Continued care in the short-term acute hospital is appropriate until the enrollee is 
stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation 
facility or 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 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 pay for electrical stimulator supplies (A4595) provided on October 
2, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that these items were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery. The tracking number provided shows that the item was 
never delivered. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies 
(A4595) provided on October 2, 2022.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. If the enrollee has chronic carbon dioxide (CO2) retention, they may benefit from bilevel positive 
airway pressure (BiPAP) during sleep as an outpatient. Medicare does not cover a home ventilator in the 
treatment of obesity hypoventilation syndrome, or when used at settings that can be provided with BiPAP. Of 
note, the average volume-assured pressure support (AVAPS) mode 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy. You say that the services should be covered. The Plan 
denied your request. The Plan says there are in-network providers that can perform this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee requires skilled services to prevent a 
decline in their function. The Plan denied your request. The Plan says a SNF admission is 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 that 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 not 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 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the eye exam provided on September 20, 
2022. 
 
You asked the Plan to reduce the copayment for the eye exam. You say that you were charged a $40 copayment 
when it should have been a $15 copayment for your annual exam. 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 $40 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 
You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the vision benefit 
category. The record shows diagnoses of vitreous degeneration of both eyes, bilateral pseudophakia, dry eyes, 
and presbyopia, which makes the eye exam medical in nature. 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 reduce the copayment 
for the eye exam provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a needle (A4215). 
 
You asked the Plan to pre-approve a needle. You say that the item should be covered. The Plan denied your 
request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a needle (A4215).
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 enrollee was discharged because their goals 
were incorrect. The facility has since adjusted their goals, but the enrollee needs to stay in the facility longer. 
The Plan denied your request. The Plan says the enrollee no longer requires skilled services on a daily inpatient 
basis and the continuation of SNF is 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 clinical documentation shows the enrollee has had some functional status 
changes. Evaluating therapists recommend ongoing skilled therapy in a SNF however the enrollee has refused 
some skilled therapy sessions and skilled nursing care. Continued daily skilled services on an inpatient basis in 
a skilled nursing facility is not medically appropriate. 
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not 
been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
such as at 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 intensive rehabilitation services are not 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at home COVID-19 test kit (87426) and sales tax (S9999) 
purchased on November 17, 2022. 
 
You asked the Plan to pay for the at home COVID-19 test kit and sales tax. You say that you were quite ill with 
the flu, and local pharmacies were out of COVID-19 test kits. You also say that you ordered a 5 pack of tests 
through Amazon, tested yourself, and you did have COVID-19. The Plan denied your request. The Plan says 
the at home COVID-19 test kit is not a covered benefit under the Plan. The Plan also says that sales tax is not 
medical in nature and will therefore never be covered under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at home 
COVID-19 test kit and sales tax are an OTC item. Medicare rules also say that Medicare does not make 
separate payment for sales tax. The Plan does not offer a supplemental benefit covering OTC COVID-19 at 
home test kits, as this is not currently required by Medicare. However, for future purchases, these can be 
obtained with participating providers and covered by Original Medicare when using your Medicare card rather 
than your Plan card. Neither Medicare nor your Plan currently offers reimbursement of purchased COVID-19 
tests. Therefore, we decided that the Plan does not have to pay for the at home COVID-19 test kit (87426) and 
sales tax (S9999) purchased on November 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) of abdomen and pelvis with 
contrast material (74177), provided on August 11, 2022. 
 
You asked the Plan to pay for the CT. You say that the services were medically necessary. The Plan denied 
your request. The Plan says any services that currently happen under the time the member is in this clinical trial 
would need to be reported with the appropriate clinical trial number. 
 
The Plan must follow Medicare rules. Medicare rules say that the clinical trial number must be reported on 
claims involving clinical trials. 
 
We looked at the file and Medicare rules. An appropriate clinical trial number was not reported for this claim. 
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 pay for a computed tomography (CT) of abdomen and 
pelvis with contrast material (74177), provided on August 11, 2022.