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

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
July 19, 2023, through July 24, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric hospitalization on July 11, 2023 with Unspecified 
Psychotic Disorder and Major Neurocognitive Disorder, Most Likely Due To Parkinsons Disease with 
Behavioral Disturbance. Based upon the review of the records provided, it was not expected that this enrollee 
would improve in a reasonable period of time beyond the dates in question as he was not showing any 
dangerousness to self or others, or auditory and visual hallucinations, and was without aggressive behaviors 
while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations, or abnormal 
behaviors. The health plans denial of continued inpatient psychiatric services appears appropriate. This 
enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was 
not a danger to himself or others and did not have any delusions, or auditory and visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve the enrollees condition 
or were for the purpose of a diagnosis. It appears that the services were supervised and evaluated by a 
physician. Based upon the review of the records provided, this enrollee does not meet the criteria for coverage 
of the acute inpatient mental health treatment provided beyond the date in question of July 19, 2023 forward 
and could have been treated in a lesser restrictive 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric hospital care provided from July 19, 2023, through July 24, 
2023.
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 due to the lack of improvement the 
enrollee requires a mobile ventilation option to successfully perform standard activities of daily living both 
around the home and outside the home. 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 a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has COPD, however there is no documentation to support the need for Life2000. Also, the enrollee has not 
tried or failed a BiPAP and there is no documentation or data to suggest deterioration. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee clearly exceeds the criteria for a 
medically appropriate acute inpatient rehabilitation admission. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare guidelines for services in an inpatient rehabilitation facility.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia, a prescription drug, oral, non-
chemotherapeutic (J8499). 
 
You asked the Plan to pre-approve the medication. You say that the requested medication is medically 
necessary for treating an unspecified illness. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Kerendia, a prescription 
drug, oral, non-chemotherapeutic (J8499).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ensure nutritional drinks. 
 
You asked the Plan to pre-approve the Ensure nutritional drinks. You say that you need the drinks to support 
your nutrition. The Plan denied your request. The Plan says the item is not a covered benefit. 
 
Medicare generally does not cover OTC services. However, the Plan offers an OTC benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the Ensure nutritional drinks are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
Ensure nutritional drinks.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve atorvastatin. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that self-administered 
drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve atorvastatin.  
 
Benefits for the drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 a simpler device has already been 
considered, tried, and deemed insufficient to treat the severity of the enrollee's disease. You say that without 
non-invasive ventilation therapy the enrollee is at a high risk for hospital readmission and potentially life-
threatening exacerbations. 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 a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
does not have the severity of illness that would justify the need for a home mechanical ventilator (HMV). The 
enrollee also does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure 
consequent to chronic obstructive pulmonary disease. There is no evidence that the enrollee has tried and failed 
a BiPAP with AVAPs that would otherwise necessitate the use of an HMV. Furthermore, the documentation 
does not support that the ventilator at issue is medically necessary and reasonable for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve the drug. You say that the enrollee has osteoporosis and have used Fosamax 
previously for a few years. You say that the enrollee has used Forteo for two years without an overlap and still 
has osteoporosis and fractures. You say that Prolia is the best possible therapy for the enrollee. The Plan denied 
your request. The Plan says that the step therapy requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that Prolia 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drugs ibandronate, pamidronate, or zoledronic acid. Also, there is no indication that the Plan's required 
drugs would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
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 despite bi-level therapy the enrollee 
has remained critically hypercarbic. You say that a BiPAP has already been considered and ruled out.  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 a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
does not appear to have the severity of illness that would justify the need for a home mechanical ventilator 
(HMV). Also, there is no evidence that the enrollee failed a trial of BiPAP with AVAPS that would otherwise 
necessitate the use of an HMV. The enrollee does not have neuromuscular disease, thoracic restrictive disease, 
or chronic respiratory failure consequent to chronic obstructive pulmonary disease. The documentation does 
not support that the ventilator at issue is medically necessary and reasonable for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that the procedure is medically 
necessary to relieve the enrollee's pain and to regain their quality of life. The Plan denied your request. The 
Plan says the genicular nerve radiofrequency ablation is considered experimental.  
 
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 the radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is considered experimental. Our physician reviewer found that 
the genicular nerve radiofrequency ablation is the subject of ongoing clinical trials and is considered 
experimental. 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the single vision prescription lens (safety athletic or 
sunglasses). 
 
You asked the Plan to pre-approve the prescription sunglasses. You say that you have later-stage macular 
degeneration which causes extreme sensitivity to light. You say you wanted a prescription for your distance 
and also protect your eyes from bright light. The Plan denied your request. The Plan says the item is not a 
covered benefit. 
 
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 not a covered benefit. 
 
We looked at the file and the Plan's rules. Specifically, sunglasses are not listed as a covered benefit under your 
routine vision benefits. Based on this information, we decided that the Plan's rules for coverage of the 
prescription sunglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the single vision prescription lens (safety athletic or sunglasses).
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 fractured your hip and  will receive the best care 
and will get well as quickly as possible in the inpatient rehabilitation facility. The Plan denied your request. 
The Plan says the records do not support that you require intensive physical therapy as you have modified 
independent for your functional mobility. The Plan says services may be provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. It 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: 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 are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval.  
 
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. The enrollee 
was admitted for lumbar spine surgery. 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 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 the required level of medical and therapy services 
cannot be accessed in another setting. The Plan denied your request. The Plan says the request 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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.