Persius/hicric huggingface dataset:
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 disagrees with this decision and wants 
an appeal. The Plan denied your request. The Plan says this request does not meet evidence based guidelines. 
The Plan also says that an alternative level of care is appropriate at this time. 
 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 member's function was at or near the prior level of function, and she could be 
discharged to a lower level of care for further 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this was denied due to lack of medical necessity and the 
criteria not met for LTACH admission. 
 
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 patient does not require services at the LTACH that are not already available at 
the current facility. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria for coverage of IRF 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee has a past medical history of stroke in 2016, diabetes and hypertension and is living at home with weakness and functional decline. The enrollees medical problems are stable. 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. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the ventilator is to be used for the treatment of 
COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator with settings 
that could be delivered by BiPAP with AVAPS for this member with COPD is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the Life2000 system is not medically 
necessary. The enrollee has COPD. According to notes from 2021, the enrollee already has a Trilogy home 
ventilator, or at least had it at that time. The Life2000 is not a true ventilator because it is not capable of 
providing full ventilatory support. There is inadequate evidence that the Life2000 is beneficial 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you treated this beneficiary in good faith, this 
service should be covered. The Plan denied your request. The Plan says there was no preauthorization by a 
primary care provider (this is different than a referral) for an OON provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on February 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to apply the in-network cost share for a specialist office visit provided 
on May 27, 2022. 
 
You asked the Plan to apply the in-network cost share a specialist office visit. You say that this provider is an 
in-network provider. 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 40% 
coinsurance for out-of-network specialty physician medical care or surgery services in a physicians office.  
 
You have been asked to pay $48.82 for a specialist office visit. This item/service falls within the specialty 
physician benefit category. 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 apply the in-network cost share for a specialist office 
visit provided on May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic imaging of the eye (92134) 
provided from April 11, 2022, to April 28, 2022. 
 
You asked the Plan to waive the copayment for diagnostic imaging of the eye (92134). You say that you should 
not have to pay these copayments because you had cataract surgery that was botched. You also say that if the 
surgery was done correctly the first time, you would not have had to go back to the provider. 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 $20 
copayment for each Medicare-covered vision services exam.  
 
 
  You have been asked to pay a $20 copayment for each diagnostic imaging of the eye (92134), for a total of $40 
($20 copayment x 2 visits = $40). This item/service falls within the Medicare-covered vision services exam 
benefit category. 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 waive the copayment for diagnostic imaging of the eye 
(92134) provided from April 11, 2022, to April 28, 2022.
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 records provided support the need for SNF care. 
The Plan denied your request. The Plan says the enrollee does not need skilled therapy services 5 days a week, 
does not need daily skilled nursing care, and can receive the care needed in another 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 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 enrollee received oral medications, had stable vital signs, and clear lungs. The 
enrollee received physical therapy and occupational therapy. The enrollee was at a minimal assist level with 
functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable 
skilled nursing service needs. While there are identifiable skilled therapy service needs, they are not required 
on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has chronic low back pain. 
The Plan denied your request. The Plan says the requested service is not covered by Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that pain management services are only covered under 
certain medical 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 the requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. He has tried physical therapy, a home exercise 
program, and radiofrequency ablation of his medial branches. The requested device is considered 
experimental/investigational for the enrollees condition. Therefore, the request is deemed not medically 
reasonable or 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SPRINT peripheral nerve stimulator.
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 the requested device. The Plan denied your request. The Plan says Medicare 
does not cover a ventilator for the requested use. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested device. Our physician 
reviewer found that you have had several recent hospitalizations. Your arterial blood gas (ABG) most recently 
was consistent with acute on chronic hypercarbic respiratory failure. The etiology is not clear from the medical 
records provided. The ordering physician is attributing the respiratory failure to critical illness myopathy, but 
there is no evidence you have been intubated or immobilized for a prolonged period.   There is no testing of muscle strength, and no pulmonary function tests showing restrictive disease with 
reduced inspiratory and expiratory mouth pressures. There is no diagnosis of COPD, thoracic restrictive 
disease, or neuromuscular disease. You may benefit from BiPAP during sleep, but Medicare does not cover a 
home ventilator when used as BiPAP. Therefore, a home ventilator 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781) and lenses (V2782) provided on 
June 29, 2022. 
 
You asked the Plan to pay for progressive lenses (V2781) and lenses (V2782). You say that your prescription 
says that your eyes need this prescription into the lens. The Plan denied your request. The Plan says they did pay the $200 benefit for eyeglasses. The Plan also says that the denied lines were because the benefit maximum 
had been reached. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the Plan covers up to a total of $200 every calendar year for 
eyeglasses, frames, lenses or contact lenses from participating network providers. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover up to $200 every calendar year for 
fames and lenses. This means that you are responsible for anything above the $200 allowance. Based on this 
information, we decided that the Plan's rules for coverage of progressive lenses (V2781) and lenses (V2782) 
have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) 
and lenses (V2782) provided on June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has 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 that the enrollee's level of function with physical therapy can improve with repetitive 
exercise with support from non-skilled personnel. The enrollee meets the standard for daily occupational 
therapy services but does not require complex or intensive therapy to improve function. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for fecal impaction. The enrollees medical problems are stable. 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. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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 IRF admission and services.
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 the requested services. The Plan denied your request. The Plan says settings 
that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee was recently hospitalized with confusion, and suggested carbon dioxide (CO2) 
retention. This was attributed to a combination of heart failure with preserved ejection fraction (HFpEF) with 
volume overload and ESRD. This enrollee does not have a diagnosis for which Medicare covers a home 
ventilator - severe COPD, neuromuscular disease, or thoracic restrictive disease. There was no arterial blood 
gas done while stable as an outpatient to document chronic CO2 retention. If the enrollee does have chronic 
CO2 retention, may benefit from BiPAP during sleep. However, Medicare does not cover a home ventilator 
when used as BiPAP. Therefore, the request 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air flotation bed system (E0193). 
 
You asked the Plan to pre-approve the air flotation bed system. You say that the requested bed system is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is covered when medically 
necessary. 
 
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 air flotation bed system. Our 
reviewer says that the requested air floatation bed system is not medically necessary.  
 
 Our physician reviewer found records do not document the patient has multiple stage 2 pressure ulcers located 
on the trunk or pelvis which have failed to improve over the past month, or the patient has large or multiple 
stage 3 or 4 pressure ulcers on the trunk or pelvis, or that the patient has had a myocutaneous flap or skin graft. 
 
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 air flotation bed system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an air flotation bed system (E0193).