Persius/hicric huggingface dataset:
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 the SNF care is medically necessary. The Plan 
denied your request. The Plan says the care the enrollee needs can safely be received at a different setting, for 
example, home with home health or outpatient therapy in residential 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 based on the medical records provided there is no documentation that the enrollee 
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Records 
do not document the need for intravenous medications, new tube feeding, or ostomy care or daily complex 
wound care or respiratory care. Based on the medical records provided the enrollee does require skilled therapy 
services. Based on the medical records provided there is documentation that daily skilled services are required. 
Provided records document a significant decline in the enrollee's functional status compared to the prior 
baseline to necessitate daily inpatient skilled therapy services. Based on the medical records provided there is 
no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Continued care in the inpatient rehabilitation facility is appropriate until the patient is stable to transfer 
to a lower level of care such as home with home health care or to a long-term care 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Minuteman procedure to the spine. 
 
You asked the Plan to pre-approve Minuteman procedure to the spine. You say that the enrollee has tried 
conservative treatments including epidural steroid injections and 3-6 months of physical therapy, but these have 
failed to provide durable, sufficient relief of their pain and other symptoms. The pain limits the enrollee's 
ability to participate in normal activities of daily living, and in turn, these limitations diminish the enrollee's 
overall quality of life. The Plan denied your request. The Plan says there are not enough studies on the 
Minuteman procedure to show it is safe and effective. Therefore, it not considered standard of care. 
 
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 Minuteman procedure to the spine. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided medical records and review of the current peer-reviewed medical 
literature do not document that use of the Minuteman procedure has been shown in controlled studies in a 
CMS-approved journal to result in sustained long term health benefits in the Medicare population with other 
intervertebral disc degeneration, lumbar region with spinal stenosis and chronic pain as described in this 
clinical scenario.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Minuteman procedure to the spine have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Minuteman procedure to the spine.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thoracic kyphoplasty with placement of stabilizing 
device using imaging guidance (22513). 
 You asked the Plan to pre-approve thoracic kyphoplasty. You say that this service is medically necessary and 
appropriate. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this 
service. 
 
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 thoracic kyphoplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documented trial of fracture bracing for this enrollee. More 
conservative measures are needed before the requested service could be considered 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 thoracic kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thoracic kyphoplasty with placement of stabilizing device using imaging 
guidance (22513).
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 needs the IRF services to regain 
independence and not rely on your spouse to complete tasks at home. The Plan denied your request. The Plan 
says the IRF services are 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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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: 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 you have no strength to walk or stand on your own 
and you need the rehabilitation services. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, but skilled therapies as an outpatient or at a skilled nursing facility may be approved upon 
request.  
 
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 in this case, the complexity of your nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
at an intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing 
safety concerns and a potential for functional improvement. However, the documentation doesnt support that 
you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that 
you would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least three visits weekly to regain or maintain your functional 
status. You can receive further services at a lower 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 a HFCWOD. 
 
You asked the Plan to pre-approve a HFCWOD. You say that the requested item is medically necessary for the 
enrollee. The Plan denied your request. The Plan says Medical necessity is not met per the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
  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 HFCWOD. Our reviewer says that the 
item is not medically necessary. Our physician reviewer found that this enrollee has a diagnosis of asthma, 
pulmonary hypertension, ischemic cardiomyopathy, congestive heart failure, and a chronic cough. There is no 
diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. A CT scan of the chest dated December 
13, 2023, describes "no bronchiectasis". This enrollee does not have a diagnosis for which Medicare covers a 
high-frequency chest wall oscillation device. There is inadequate medical evidence indicating that this device is 
beneficial in the treatment of this enrollees conditions. The denial is upheld. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a HFCWOD.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from July 6, 2023, to July 9, 2023. 
 You asked the Plan to pay for SNF care. You say that the enrollee required daily skilled nursing services. The 
Plan denied your request. The Plan says the enrollee did not require daily skilled nursing services from July 6, 
2023, to July 9, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 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 did not require daily skilled nursing or therapy services. The enrollee did 
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 pay for SNF care provided from July 6, 2023, to July 9, 2023.
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 to inpatient rehabilitation is medically 
necessary. The Plan denied your request. The Plan says admission to inpatient rehabilitation 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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 you 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
August 28, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you thought your 
would have the $50 urgent care copay. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room services. This item/service falls within 
the emergency care 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 the emergency room 
services provided on August 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frame, the single vision lens, the tint, the 
antireflective coating, and the ultraviolet lens provided on July 21, 2023. 
 
You asked the Plan to pay for the vision services. You say that you were told that insurance would cover $300 
of your vision services. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 provides a $300 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses. 
 
We looked at the file and the Plan's rules. Specifically, the Plan deducted $300 off the price of the eyewear, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the 
vision services have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe 
frame, the single vision lens, the tint, the antireflective coating, and the ultraviolet lens provided on July 21, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) (K0861) with 
multiple power options and accessories. 
 
You asked the Plan to pre-approve K0861 PWC. You say that this is required for the enrollee. The Plan denied 
your request. The Plan says the enrollee does not require the power options to necessitate the requested K0861 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules state that a Group 3 PWC may be covered if certain 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 K0861 PWC. Our reviewer says that 
the enrollee does not meet criteria for a K0861 PWC. Our physician reviewer found the enrollee does not have 
high risk for skin breakdown, use a catheter intermittently, have spasticity, or require an alternative means of 
managing power drives. The enrollee's condition does not meet criteria for power tilt or recline. 
 
As the base power wheelchair does not meet coverage criteria, all related components are also denied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of K0861 PWC have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) (K0861) with multiple power options and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the continued use of a home ventilator. 
 
You asked the Plan to pre-approve  the continued use of a home ventilator. You say that advanced ventilation 
was deemed necessary and non-invasive ventilation was ordered for home use to better manage his CO2 
retention and provide respiratory support for exertional distress in the daytime. 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  the continued use of a home ventilator. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found this enrollee has 
COPD, congestive heart failure, obstructive sleep apnea, and obesity hypoventilation syndrome. There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. The enrollee was recently hospitalized with 
COVID-19 pneumonia, requiring intubation for respiratory failure. Arterial blood gases were consistent with 
acute on chronic hyper carbic respiratory failure. The enrollee previously had a home ventilator but was unable 
to tolerate it. This enrollee may benefit from BiPAP with a volume assurance mode as an outpatient if 
compliance can be achieved. 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  the continued use of a home ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve  the continued use of 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 the services are medically necessary. The Plan 
denied your request. The Plan says your condition does not meet Medicare medical necessity criteria for skilled 
nursing facility. 
 
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 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 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.