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

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that it is medically necessary for the 
enrollee to have the home ventilator. You say that discharging the enrollee without the support they need could 
lead to readmission to the hospital as well as a risk for death. The Plan denied your request. The Plan says a home ventilator is not medically necessary for this patient because their needs can be met with an alternative 
device such as a 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. This enrollee was recently hospitalized for cervical spine surgery and developed 
hypercarbic respiratory failure postoperatively related to narcotic treatment of pain. The enrollee has severe 
obesity and suspected obstructive sleep apnea. There is a known elevated right hemidiaphragm. Pulmonary 
function tests on October 19, 2023, were consistent with severe restrictive lung disease. Arterial Blood Gasses 
(ABGs) were consistent with acute on chronic hypercarbic respiratory failure. There is no diagnosis of COPD, 
thoracic restrictive disease or neuromuscular disease. This enrollee may benefit from BiPAP with average 
volume assured pressure support (AVAPS) during sleep as an outpatient. The records do not show this has 
been tried as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment but is still somewhat 
unstable and requires additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer. The enrollee 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours of home health services. 
 
You asked the Plan to pre-approve the aide services. You say that the enrollee was discharged home instead of 
a skilled nursing facility. The enrollee is a fall risk and needs home health to improve mobility so she can 
perform daily living activities. The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation shows that there has been clinical and functional status change however there is no plan of care 
in which the services of a skilled professional home health aide would be medically required. Additionally, 
clinical documentation concerns address mobility and self-care impairments as opposed to home health aide 
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 the aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional hours of home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation using mechanical device, 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging 
guidance: lumbar (22514). 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that you are requesting 
reconsideration and have attached medical records for review. The Plan denied your request. The Plan says the 
request is not medically necessary because the records show you have chronic back pain and your MRI 
imaging from May 2023 showed an L2 compression fracture.  
 
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 percutaneous vertebral augmentation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found detailed documentation is not evident regarding an acute or subacute 
fracture at L2. The noted compression fracture was noted on the MRI dated May 22, 2023, (as well as the 
September 10, 2023, CT scan.) Additionally, there is no documentation of a progression of the body height 
loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. 
Moreover, there is an MRI corroboration of retropulsion and other plausible causes of pain. Therefore, you do 
not meet the criteria for the requested procedure. 
 
 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 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity creation using 
mechanical device, 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance: 
lumbar (22514).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) (22513). 
 
You asked the Plan to pre-approve PVA. You say that the enrollee has been suffering with a fracture of the T12 
vertebrae and is in a lot of pain and discomfort. The Plan denied your request. The Plan says the records show 
that the fracture is greater than 12 weeks old. The Plan also says that the requested procedure is not medically 
necessary. 
 
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 PVA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding an acute or subacute compression fracture at 
T12. Additionally, there is no documentation of a progression of the body height loss, kyphotic deformity, or a 
severe impact on daily activities. Moreover, there is an MRI corroboration of retropulsion and other plausible 
causes of pain. Therefore, the enrollee does not meet the coverage criteria for a T12 kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous vertebral augmentation (PVA) (22513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee has tried conservative 
treatments with no relief. The Plan denied your request. The Plan says the requested procedure is not medically 
necessary. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) evidence of modic changes without 
facet degenerative joint disease. The cause of pain is not clear. Medicare criteria is not 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (64628, 64629).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the requested home health services are 
medically necessary.  The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what have already been approved. 
Records document the enrollee has been educated on their disease process and medications. No medical notes 
from the enrollees treating physician are provided documenting an order or need for additional skilled nursing 
services. Records do not document the need for intravenous medications, new tube feeding or ostomy care or 
complex wound 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health 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 records provided support the need for SNF care. 
The Plan denied your request. The Plan says 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. 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 has diabetes, cognitive impairment, anemia, hypertension and back pain. 
The enrollee received oral medications and insulin and had stable vital signs. There are not records to 
substantiate the need for skilled therapy. The enrollee does not show to require skilled nursing or therapy 
services on a daily basis. This 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown for tooth #14. 
 
You asked the Plan to pre-approve the requested crown. You say that the crown needs to be replaced. The Plan 
denied your request. The Plan says that there is no evidence of decay or missing crown to support the need for 
replacement. An open margin without documented presence of active recurrent decay does not meet criteria for 
crown replacement. Aesthetics is also not included as a need for replacement of the existing crown. 
 
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. The Plan covers the requested 
crown when the services are medically necessary and reasonable. 
 
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 crown. Our reviewer says 
that the requested crown is found to be reasonable and necessary based on the criteria. Our physician reviewer 
found a review of the documentation indicates that the crown that was in place for over 7 years fractured. The 
crown was removed, and a core buildup was approved. A new crown is medically reasonable and necessary to 
provide adequate masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the requested crown have been met. Therefore, we decided that the Plan has to 
pre-approve a crown for tooth #14.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the enrollee needs assistance with their 
medication monitoring. The Plan denied your request. The Plan says there is no evidence to support the need 
for continued nursing visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continuation of home health skilled nursing visits.
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 would like reconsideration based on the records submitted.  
The Plan denied your request. The Plan says  the enrollee's status does not meet severity or intensity medical 
necessity criteria for a SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: 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 is getting stronger but not to the point 
where they should be yet. The Plan denied your request. The Plan says there is no documentation to support the 
medical necessity for continued skilled services of any type 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 enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist; 
however, they do not require skilled therapy services on a daily basis. The enrollee does not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. This 
enrollee does 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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chemotherapy regimen to include Keytruda, 
Carboplatin, Pemetrexed, Dexamethasone, Palonosetron, and Fosaprepitant. 
 
You asked the Plan to pre-approve a chemotherapy regimen to include Keytruda, Carboplatin, Pemetrexed, 
Dexamethasone, Palonosetron, and Fosaprepitant. You say that the requested drug regimen are medically 
necessary to treat the enrollee's lung cancer. The Plan denied your request. The Plan says the documentation 
provided shows the enrollee has progressed while taking Keytruda. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  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 chemotherapy regimen to include 
Keytruda, Carboplatin, Pemetrexed, Dexamethasone, Palonosetron, and Fosaprepitant. Our reviewer says that 
the requested chemotherapy regimen does not meet the criteria necessary for approval. Our physician reviewer 
found the enrollee has completed radiation with chemotherapy and 14 cycles of pembrolizumab (Keytruda). 
Recent imaging has shown progression of the enrollee's disease while receiving maintenance immunotherapy 
with pembrolizumab. The intended use for the requested regimen is not supported by one of the major dug 
compendia or by clinical research. Therefore, the requested regimen is not FDA-approved for the enrollee's 
current diagnosis and progression. 
 
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 chemotherapy regimen to include Keytruda, Carboplatin, Pemetrexed, 
Dexamethasone, Palonosetron, and Fosaprepitant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a chemotherapy regimen to include Keytruda, Carboplatin, Pemetrexed, 
Dexamethasone, Palonosetron, and Fosaprepitant.