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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 
requested device is not medically reasonable or necessary. Our physician reviewer found that the enrollee does 
not have a condition that warrants the use of this device. The enrollee also does not show failure of any 
standard therapy. Hence, there is no indication for this device. 
 
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 high frequency chest wall oscillation device (HFCWOD).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the services. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says that the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that Our reviewer found that the records only consist invoices for home 
health aide services. The plan has not submitted any evidence are not necessary or have not been provided. We 
found that the plan has not substantiated their denial. Therefore, we decided that the Plan has to pre-approve 
home health aide services.  
 
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: 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 cannot be safely discharged home. They 
require IRF services in order to get stronger and to regain their prior level of functioning. 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting a reconsideration of 
the services. The Plan denied your request. The Plan says the enrollee can receive this care in their current 
acute care setting. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left knee arthroscopy 
 
You asked the Plan to pre-approve a left knee arthroscopy. You say that the enrollee has received cortisone 
injections on March 16, 2023, and September 27, 2023. These injections did not provide the enrollee with any 
relief. You say that as the enrollee has tried and failed conservative measures, surgery would be the next best 
option. The Plan denied your request. The Plan says the requested left knee arthroscopy 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 a left knee arthroscopy. Our reviewer 
says that the requested left knee arthroscopy is not considered medically reasonable and necessary in this case. Our physician reviewer found that a formal magnetic resonance imaging (MRI) study of the left knee was not 
provided for review corroborating the meniscal tear. The noted study did not include a date. Moreover, the  
x-rays provided corroborated significant osteoarthritis of the left knee. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 left knee arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left knee arthroscopy
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 22, 
2023, to June 20, 2023. 
 You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied 
your request. The Plan says the enrollee's condition no longer required daily skilled services at an 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 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 have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
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 pay for skilled nursing facility (SNF) care provided from May 22, 2023, to June 20, 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 lower level care is failing the enrollee. They need 
IRF services to regain their prior level of functioning with less family assistance. 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary care services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve primary care services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says they are unable to approve your request to see 
out-of-network providers past the 90 days of your enrollment with your Plan. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
primary care services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on August 12, 2022. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cover some vaccines under the Part D drug 
benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on 
August 12, 2022.  
 
Benefits for immunization services 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two (2) skilled nursing home health visits (G0299, 
G0151). 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration and 
have submitted medical records for review. 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 the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two (2) skilled nursing home health visits (G0299, G0151).
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 requires an IRF level of care. The Plan 
denied your request. The Plan says the enrollee's therapy needs can be met at a lower level of care such as a 
SNF.  
 
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 
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 or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the requirements for an IRF 
admission.  
 
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 
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 or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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 ondansetron. 
 
You asked the Plan to pre-approve the medication. You say that records have been provided to show medical 
necessity. 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 ondansetron.  
 
Benefits for the medication 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kesimpta 
 
You asked the Plan to pre-approve the medication. You say that the preferred alternative drugs are less 
effective, and the requested drug is the treatment of choice for the enrollee's diagnosis. 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 Kesimpta  
 
Benefits for the medication 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: 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 would benefit from advanced therapy at 
an IRF to optimize recovery. The Plan denied your request. The Plan says the IRF services requested do 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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is 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, but the services required can be provided 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.