Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on September 27, 2022, 
through September 28, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service was medically necessary. 
The Plan denied your request. The Plan says that the service 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on September 27, 2022, through September 28, 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: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room (ER) services, provided on July 4, 2022. 
 
You asked the Plan to pay for the ER services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that that at the time this service was performed, provider requirements were 
not 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 did not submit any documentation on what or why provider 
requirements were not met. Therefore, we decided that the Plan has to pay for the emergency room (ER) 
services, provided on July 4, 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional 
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 medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility.  The elements of the coverage rules are 
not satisfied. 
 
 
 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services provided on April 11, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that this procedure exceeds the maximum number of services allowed. 
 
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 has not provided information on why the services exceed the maximum 
allowed or what guidelines were used. Therefore, we decided that the Plan has to pay for the radiology services 
provided on April 11, 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care after March 6, 2023. 
 
You asked the Plan to pre-approve SNF care after March 6, 2023. You say that the continued SNF care is 
medically necessary. The Plan denied your request. The Plan says that the continued SNF care 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 after March 6, 2023. Our 
reviewer says that the requested SNF care is considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found based on the medical records provided this enrollee does require 
skilled therapy services. Provided records document a significant decline in the enrollees functional status 
compared to recent baseline. There is documentation that daily skilled services are required. As of March 2, 
2023, the enrollee was walking 5 feet x 2 with a rolling walker with moderate assistance and was minimum to 
contact guard assist for transfers and set up assist to maximum assist for activities of daily living. The enrollee 
is reported to be making gains with therapy treatment and continued treatments five days per week are 
recommended. Her baseline was reported to be ambulatory up to 150 feet with a walker with modified 
independence and modified independent for transfers. Provided records document a significant decline in the 
enrollees functional status compared to her recent baseline to necessitate further daily inpatient skilled therapy 
services. As a practical matter, continued services on an inpatient basis in the skilled nursing facility setting 
appear to be reasonable and necessary in an effort to return the enrollee to her recent baseline level of 
functioning. 
 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 after March 6, 2023, have been met. The Plan must continue coverage 
for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has 
been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-
approve continued skilled nursing facility (SNF) care after March 6, 2023.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies provided on August 
8, 2022. 
 
You asked the Plan to pay for the ambulance oxygen and oxygen supplies. You say that the medical records 
provided support the need for the requested air ambulance transport. The Plan denied your request. The Plan 
says supplies are considered part of the general ambulance service and payment for them is included in the 
payment rate for the transport 

The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies provided on August 
8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation at L4. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation at L4. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is only covered 
for certain indications. 
 
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 percutaneous vertebral augmentation at 
L4. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the enrollee was being treated for wedge compression 
fracture of fourth lumbar vertebrae. However, detailed documentation is not evident regarding a trial and 
failure of recent, reasonable, comprehensive less invasive conservative care measures. The enrollees most 
recent conservative care treatments was physical therapy, and that was noted to be one and a half years ago. 
Moreover, multiple other plausible pain generators including at the lumbosacral spine are evident. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the enrollee does not meet criteria for the 
requested 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 percutaneous vertebral augmentation at L4 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous vertebral augmentation at L4.
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 LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an LTACH care. The plan will continue to cover medically necessary acute 
and critical care at the current facility until the enrollee's condition is stable for transfer to an alternate level of 
care (such as a skilled nursing facility), or until the clinical circumstances change such that LTACH may be 
reconsidered. 
 
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 the 
enrollee 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital stay. 
 
You asked the Plan to pre-approve inpatient hospital stay. You say that you want the Plan to cover the services. 
The Plan denied your request. The Plan says no clinical information was submitted for review. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient hospital stay have been met. 
There are no medical records within the casefile. Without the requested clinical information, we are unable to 
determine if the requested services are medically necessary. Therefore, we decided that the Plan does not have 
to pre-approve inpatient hospital stay.
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 you are requesting reconsideration for the denial of 
a SNF admission. You say you need more therapy before returning home. The Plan denied your request. The 
Plan says the SNF admission you requested 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist however, you do not require 
skilled therapy on a daily basis. You do not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity of service 
criteria for 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) provided on September 27, 2021, and the consultation - diagnostic service (D9310) provided on June 
17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were advised that the provider would be in-
network with the new dental plan you were selecting. The Plan denied your request.  The Plan says your benefit for the intraoral - periapical each additional radiographic image (D0230) has already 
been exhausted, and the consultation - diagnostic service (D9310) is not covered under the Plans dental 
benefits. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral - periapical each additional radiographic image (D0230) was exhausted on 
date of service September 27, 2021. Therefore, we decided that the Plan does not have to pay for intraoral - 
periapical each additional radiographic image (D0230) provided on September 27, 2021, and the consultation - 
diagnostic service (D9310) provided on June 17, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Ferumoxytol injection. 
 
You asked the Plan to pre-approve the injection. You say that this si medically necessary. The Plan denied your 
request. The Plan says the enrollee's clinical condition is stable and the step therapy requirement to trial an oral 
iron replacement has not occurred. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that there is no 
indication that the enrollee has tried and failed ferrous sulfate, ferrous gluconate, or ferrous fumarate. Based on 
the medical records provided and the Medicare-approved major drug compendia there is no indication that the 
plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Ferumoxytol injection.
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 requires a multidisciplinary team of 
nurses, therapists to manage medical needs. The Plan denied your request. The Plan says while the enrollee will 
likely benefit from ongoing therapy to enhance their rehabilitation potential, there is no evidence that this 
cannot safely be done at a lower level of care. 
 
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 does not need intensive therapies with multidisciplinary approach in an 
IRF. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and portable system from April 
30, 2023-forward. 
 
You asked the Plan to pre-approve an oxygen concentrator and portable system. 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 follows Medicare rules. Medicare rules say that home use of oxygen is covered when specific 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 an oxygen concentrator and portable 
system. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
on the medical records provided there is no documentation that the oxygen concentrator and portable system 
from April 30, 2023-forward at issue in this case meets all Medicare criteria for medically reasonable and 
necessary for you. Provided records in this case do not document a medical evaluation within 90 days of the 
time period in question which documents hypoxemia to meet criteria for coverage of the oxygen concentrator 
and portable system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oxygen concentrator and portable system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an oxygen concentrator and portable system from April 30, 
2023-forward.