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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the records provided support the need for a 
home ventilator. You say that the requested machine is needed so that your body doesn't fill up with poisonous 
carbon dioxide. You say that you had a house fire, and your Trilogy machine was damaged in the fire. The Plan 
denied your request. The Plan says the requested device is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. The enrollee has severe chronic obstructive pulmonary disease (COPD) with a recent 
hospitalization for acute on chronic hypercarbic respiratory failure. A Trilogy ventilator was prescribed and provided on discharge. According to the enrollee's appeal note, the ventilator was damaged in a house fire and 
needs replacement. There is no documentation from the ventilator vendor that it is not repairable, and there is 
no documentation of compliance with use. The enrollee did not meet Medicare criteria for coverage of a 
ventilator at discharge, because bi-level positive airway pressure (BiPAP) with average volume-assured 
pressure support (AVAPS) was not tried and documented to fail at home. The enrollee was reportedly 
intolerant of either BiPAP or a ventilator previously.  The enrollee should be started on BiPAP with AVAPS.  
Medicare does not cover a ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan of the skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve the PET CT scan services. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a PET scan will not be covered for an enrollee 
recently diagnosed with prostate cancer. Therefore, we decided that the Plan does not have to pre-approve the 
positron emission tomography (PET) scan with concurrently acquired computed tomography (CT) scan of the 
skull base to mid-thigh (78815). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PET CT scan services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the positron emission tomography (PET) scan with concurrently acquired computed tomography 
(CT) scan of the skull base to mid-thigh (78815).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an axial rotation unit and flex-walk system or equal for 
the enrollee. 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that this request exceeds the member's needs and cannot be covered. 
 
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 items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. The request appears to 
exceed the patient's medical need. There is no evidence of a K3 level of ambulation on the physician medical 
progress notes therefore this request is not medically necessary. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these 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 these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an axial rotation unit and flex-walk system or equal for the enrollee.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of 
complex wound care, new enteral feedings, or other skilled nursing SNF need. You are independent in 
colostomy care. You have no complex wounds. Your functional level does not require skilled therapy services 
with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide 
medically necessary and reasonable treatment in a SNF. You are near baseline function. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a 
practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pay for the admission. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the admission. Our reviewer says that the 
requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee has 
stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing 
and/or skilled therapy services on a daily basis.  She is medically stable and can receive further rehab services 
at a lower level of care. Although further rehab services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing 
facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a 
feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her 
physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a 
SNF for inpatient skilled rehab services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pay for admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you have unsafe living conditions and no help. 
You say that you need therapy and will decline if you return home. The Plan denied your request. The Plan 
says the guidelines for coverage of SNF care have not been met. The Plan says that the services required can 
safely be received at a different 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital.  The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis.  He is medically stable and can receive further rehabilitation services at a lower level 
of care.  Although further rehabilitation services would be appropriate to improve function, as a practical 
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 
The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube.  
He is medically stable without any acute exacerbations of chronic medical problems.  His physical function is 
at or near his baseline and he can receive services at a lower level of care.  Admission to a SNF for inpatient 
skilled rehabilitation services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need including therapy services 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of diabetic 
polyneuropathy, lumbar radiculopathy, congestive heart failure, and atrial fibrillation and are living at home 
with complaints of weakness and trouble with transfers. Your medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF 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: 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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of 
complex wound care, new enteral feedings, or other skilled nursing SNF need. Your high functional level does 
not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist 
to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a 
practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve additional routine transportation services. You say that this is medically 
necessary for your condition. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 3, 2021, to January 4, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says the services could have been rendered in another setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department (ED) with dysuria. Vitals were 
normal and stable. The patient was not in acute distress. The examination findings were unremarkable. The 
enrollee was treated for uncomplicated urinary tract infection with IV antibiotics, and then quickly transitioned 
to oral the next day. There was no expectation at the time of admission that the patient would require hospital 
services that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from January 3, 2021, to 
January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a specialized mattress. 
 
You asked the Plan to pre-approve continued use of a specialized mattress. You say that this mattress continues 
to be medically necessary. The Plan denied your request. The Plan says the continued use of this mattress does 
not satisfy Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that continued use of a group 2 support surface is 
covered until the ulcer is healed. In this case, the enrollees ulcers have healed. Based on this information, we 
decided that Medicare rules for coverage of continued use of a specialized mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued use of a specialized mattress.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says SNF care is medically reasonable and 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and are 
ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a 
daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although 
further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility. You do not have any parental 
medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any 
acute exacerbations of chronic medical problems. Your physical function is at or near the baseline and you can 
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the 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. The plan's decision states that "MD provides correct fax form and attests the 
patient is NOT using insulin at least 3 times per day (claims history supports use only with Lantus), and no 
frequent adjustments." The plan has provided no proof of this in the very limited case file. There are no forms 
or records from the aforementioned MD included in the file. Claims history has not been provided. The plan 
has not substantiated their denial in this case. Therefore, we decided that the Plan has to pre-approve a 
Freestyle Libre.  
 
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 inpatient hospital services provided to the enrollee from 
November 6, 2021, to November 9, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be reconsidered. The Plan 
denied your request. The Plan says an inpatient stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee had reported chest pain, dizziness and was feeling "foggy." Vitals were 
normal upon evaluation. The rest of the workup did not reveal an acute condition which would warrant 
inpatient services. There was no suggestion at the time of admission that the patient would require hospital 
services that would likely cross 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from November 6, 2021, to 
November 9, 2021.