Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that it is important that this doctor see the progress that has been made on your eyes and if 
there should be something wrong, he should fix it, not a new doctor. The Plan denied your request. The Plan 
says the requested service is available in-network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESIs). 
 
You asked the Plan to pre-approve epidurals. You say that all of the criteria for medical necessity are met. The 
Plan denied your request. The Plan says the records do not show that the enrollee experienced sustained 
improvement in pain or function from the previous injection. 
 
The Plan follows Medicare rules. Medicare rules state that repeat ESI is only covered when the record 
documents at least 50% sustained improvement in pain and/or function for at least 3 months. 
 
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 epidurals. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found the enrollee did not have 
sustained 50% pain relief from the previous injection. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidurals have not been met. Therefore, we decided that the Plan does not have 
to pre-approve epidural steroid injections (ESIs).
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 patient needs this item because her 
ability to breathe is severely impaired and she needs constant ventilation. The Plan denied your request. The 
Plan says the patient's needs can be met with a bilevel positive airway pressure (BiPAP) device with average 
volume-assured pressure support (AVAPS). 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the enrollee is a 74-year-old 
female with a past medical history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease, and 
obstructive sleep apnea. She has been using a non-invasive ventilator in average volume assured pressure 
support mode since January 4, 2023.  The enrollee was evaluated by her provider on March 14, 2023, and at 
that time, continuation of her non-invasive ventilator in this mode was recommended. A standard written order 
for continuation was placed on March 15, 2023. She has not had any recent studies to investigate the presence 
of hypercapnia or hypoxia. With this request for continuation of the NIV, there was no change in the order for 
the device, or in the settings requested according to the standard written order dated January 4, 2023. The 
compliance data submitted by the durable medical equipment provider from the time period of March 11, 2023, 
to April 9, 2023, indicates the machine is being used in AVAPS mode, and no other modes. The documentation 
submitted fails to indicate that she is requiring the home ventilator for use in other than bilevel positive airway 
pressure (BiPAP) or BiPAP with AVAPS mode. The records we received from her provider do not show she 
has failed the use of BIPAP or BIPAP with AVAPS when she is at her baseline level of breathing. 
 
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: 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 patient requires a ventilator for 
treatment of COPD. Other devices cannot provide the volume control that the patient requires. The Plan denied 
your request. The Plan says the patient's needs can be met with a bilevel positive airway pressure (BiPAP) 
device with average volume-assured pressure support (AVAPS). 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic obstructive pulmonary disease (COPD). She was hospitalized in March of 2023 for acute on chronic 
respiratory failure in the setting of pulmonary edema and volume overload. The hospital treatment included use 
of a bilevel positive airway pressure (BiPAP) and medications to help with breathing and fluid management. 
The enrollee was initially prescribed a non-invasive ventilator (NIV) in November of 2021 for use exclusively 
in a VAPS mode, which is a setting available on BiPAP devices. Compliance data from May 8, 2023, to June 6, 
2023. demonstrates average daily use of the NIV for 9 hours and 49 minutes exclusively in a VAPS setting. 
The documentation submitted fails to indicate that the enrollee is requiring the NIV for use in other than bilevel 
positive airway pressure (BiPAP) or BiPAP with AVAPS mode or that she has failed the use of BiPAP or 
BIPAP with AVAPS in the past. The documentation does not support that this device meets but does not 
exceed the enrollee's need. The documentation does not support that at the time of initial prescription for the 
device, the use of a CPAP or BiPAP device would not have met the enrollee's medical needs or that BiPAP 
with AVAPS had been considered and ruled out. Further, the NIV device is currently prescribed for use in a 
BIPAP with AVAPS mode which exceeds the current medical need. In addition, documentation related to 
compliant and adequate ongoing use of the device was not submitted with the appeal. 
 
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: 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 you are appealing this denial. The Plan denied your 
request. The Plan says the denial of SNF care is correct. 
 
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 not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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: 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 patient has severe chronic respiratory 
failure and COPD. Other devices have been considered and ruled out as they cannot adequately manage the 
patient's respiratory disease. The Plan denied your request. The Plan says the patient's needs can be met with a 
bilevel positive airway pressure (BiPAP) device with average volume-assured pressure support (AVAPS). 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the enrollee has COPD. The 
records indicate that he was seen by his provider on March 22, 2023, and the office visit notes indicate that he 
has chronic respiratory failure and uses home oxygen. His arterial blood gas (ABG) showed a CO2 level of 54. 
He was admitted to the hospital in March of 2022 with pneumonia. The provider diagnosed him with an acute 
exacerbation of COPD and prescribed antibiotic and steroids. You stated that the patient needs a non-invasive 
ventilator (NIV) for Average Volume Assured Pressure Support therapy mode (AVAPS), which can be 
delivered by bi-level PAP machine with AVAPS capability. The review indicates that the request is not 
medically necessary because the records show that the ordered settings for the noninvasive ventilator can be 
delivered by a bi-level PAP machine with AVAPS capability. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that Botox is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says rules for coverage have not been met. 
 
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 Botox have been met. Specifically, the 
case record does not show that medical records supporting the medical necessity of the requested item/service have been provided for review. Therefore, we decided that the Plan does not have to pre-approve treatment 
with Botox (J0585).
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. The Plan denied your request. The Plan says the 
enrollee no longer require an inpatient level of care and the services currently receiving can be safely rendered 
at a lower level of care such as a skilled nursing facility. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 pre-approve a replacement Group 2 power wheelchair (PWC) with 
captain chair (K0823) and electric power lift (E1399). 
 
You asked the Plan to pre-approve a replacement PWC and electric power lift. You say that the enrollee's 
current power wheelchair is not operating properly. You say that it is running and slamming the enrollee into and out of things. You also say that this is dangerous. The Plan denied your request. The Plan says the electric 
lift device is intended for outdoor use to lift your power wheelchair out of the elements and transport, and 
therefore is noncovered. The Plan also says it is not clear that your power wheelchair has sustained irreparable 
damage, nor is it clear that this irreparable damage is from a specific accident or natural disaster. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment, or less than five years. The rules state that for equipment to be 
covered, it must be appropriate and needed for use inside the home. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a replacement PWC and electric power lift have not been met. The file indicates that the enrollees 
current PWC is less than five years old. The file also indicates that electric power lift is for use outside of the 
home. Therefore, we decided that the Plan does not have to pre-approve a replacement Group 2 power 
wheelchair (PWC) with captain chair (K0823) and electric power lift (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the requested PET scan is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the requested PET scan is not medically necessary. Our physician reviewer found An FDG PET scan is 
considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive 
decline of at least 6 months, who meet diagnostic criteria for both AD and FTD. These patients have been 
evaluated for specific alternate neurodegenerative diseases or other causative factors, but the cause of the 
clinical symptoms remains uncertain. In this case the member is not noted to meet diagnostic criteria for both 
AD and FTD. There is also a diagnosis of normal pressure hydrocephalus noted as well. In this setting the initial requirement of the Medicare NCD for coverage of the requested study would not be met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: 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 enrollee will require another 3-4 
weeks to continue weaning down Oxygen needs and to transition from acute illness. The Plan denied your 
request. The Plan says the enrollee's records do not show that continued treatments and care can only be given 
in a hospital setting. Services needed may be provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet all the requirements. Services needed 
may be provided safely in 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve OON services. You say that this doctor is the only one who can provide the 
services. The Plan denied your request. The Plan says network providers are available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
cardiology services 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 the submitted medical records support the need for 
IRF admission. The Plan denied your request. The Plan says the requested IRF admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
While the medical records support 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 the 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 acute IRF admission and services.