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

 
We decided that the Plan does not have to pre-approve wound care supplies (A6233, A6260 X2, A4216 X5, 
A4217 X30, and A4450 X5) 
 
You asked the Plan to pre-approve wound care supplies. You say that you were only approved for certain 
things and were denied for cleansers/solution to help with the cleaning the wound and to promote healing. The 
Plan denied your request. The Plan says the medical notes received do not support the need for this service. 
 
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 wound care supplies. Our physician 
reviewer found that based on Local Coverage Article (A54563) stating that the member's wound does not meet 
the guideline. Therefore, member is denied to get sterile water, tape, cleanser and gauze as it is not medically 
necessary. Member was only approved for absorptive dressing (A6252 X30), bandage (A6446 X60) and foam 
dressing (A6214 X30) under authorization 562789. Moreover, appeal investigation revealed that the member 
does not meet the criteria for hydrogel dressing (A6233) per LCD L33831. CPT Code A6260 as well as A4216 
and A4217 for sterile water were listed as non-covered because they do not meet the statutory definition of a 
dressing. The review has determined that regarding the requested  wound care did not meet the requirements 
listed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound care supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve wound care supplies (A6233, A6260 X2, A4216 X5, A4217 X30, and A4450 X5)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system 
(CPT Code E2300) and wheelchair accessory, power standing system (CPT Code E2301). 
 
You asked the Plan to pre-approve the accessories. You say that the accessories are necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the accessories have not been met. The rules say that a power seat 
elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily 
medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if 
the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as 
non-covered. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessory, power 
seat elevation system (CPT Code E2300) and wheelchair accessory, power standing system (CPT Code 
E2301).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says family training is considered discharge planning and should be secured before transfer 
from the acute care 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 above. 
 
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 does not meet the CMS coverage criteria for an IRF admission based on 
lack of medical and nursing needs. She is medically stable after severe sepsis from pneumonia and occluded 
trach cannula. There is no documented evidence of medical issues that require monitoring by an inpatient rehab 
physician three times a week. The documentation does not support that there is a need for an intensive therapy 
program with 3 hours a day and an interdisciplinary approach to rehab care at the current functional status. She 
will not be able to make a significant functional recovery in a predicted period with preexisting dependency in 
her function. The enrollee's rehab needs can be met in an alternate, less intense setting such as in a custodial 
care with 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve 3 additional routine transportation trips. 
 
You asked the Plan to pre-approve 3 additional routine transportation trips. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says that you have exhausted your 
routine transportation benefit for the 2020 benefit year. 
 
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. The Plan says that you have used all allotted routine transportation trips for the 
2020 benefit year; however, the Plan has not provided any documentation showing that you have used all 30 
trips. The Plan also has not provided any supplemental benefit manual that shows what coverage criteria have 
not been met. Therefore, we decided that the Plan has to pre-approve 3 additional routine transportation trips.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System. 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the requested CardioMEMS HF 
System is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
System 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 CardioMEMS HF System. Our 
reviewer says that the requested CardioMEMS HF System is not medically necessary. Our physician reviewer 
found the enrollee is with a history of hypertension, GERD, coronary disease, ICD placement, hypothyroidism, 
obesity, prior smoking and NYSHA Class III congestive heart failure with reduced LV ejection fraction (LVEF 
25-30%) requiring hospitalization. 
 
In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated 
in only one trial to help reduce hospital readmission compared to standard medical therapy.  Moreover, 
concerns have been raised about potential bias in this trial calling into question the results. Therefore, the 
efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not 
recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met 
since the device should still be considered experimental or investigational. 
 
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 CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sondercare total electric hospital bed. 
 
You asked the Plan to pre-approve a Sondercare total electric hospital bed. You say that you continue to fall 
and need a hospital bed. The Plan denied your request. The Plan says that total hospital beds are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a Sondercare total 
electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient psychiatric hospital care after September 20, 
2020. 
 
You asked the Plan to pre-approve continued psychiatric inpatient care. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that that the enrollee can safely be treated in 
a different setting. 
 
The Plan must follow Medicare rules. Before discharging an enrollee from an inpatient hospital level of care, 
Medicare rules say that the Plan must obtain concurrence from the physician who is responsible for the 
enrollee's inpatient care. 
 
In this case, the record does not show that the physician responsible for the enrollee's inpatient care concurs 
with this discharge. Therefore, we decided that the Plan has to pre-approve continued inpatient psychiatric 
hospital care after September 20, 2020.  
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency
transport, (bls) (CPT Code A0428).
You asked the Plan to pre-approve the ambulance services. You say that the member requires transportation to
dialysis session by ambulance because the member cannot tolerate sitting in the wheelchair due to weakness in
their hands and legs. You state member is a fall risk. and the doctor also checked that the member is confused
and needs a medical attendant present during transport. The Plan denied your request. The Plan says based on
the clinical records received, there is no documentation that the member is unable to get up from bed without
assistance, unable to ambulate and unable to sit in a chair or a wheelchair.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 ambulance services. Our physician
reviewer found the enrollee required transport for scheduled hemodialysis. The provider completed a physician
certification statement noting the enrollee had weakness in the extremities. Additionally, noted the enrollee is
confused and required an attendant. Patient progress notes state the enrollee was in no distress, conversant and
stable on maintenance hemodialysis. The records do not support the enrollee could not have safely been
transported for hospital evaluation by other means. Medical necessity is not supported.
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 ambulance services have not been met. Therefore, we decided that the Plan
does not have to pre-approve ambulance service, basic life support, non-emergency transport, (bls) (CPT Code
A0428).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build up (D2950).You asked the Plan to pre-approvethe core build up. The Plan denied your request. The Plan says core build up is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecore build up (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injections of lower or sacral spine facet joint using 
imaging guidance (64495, 64493 and 64494). 
 
You asked the Plan to pre-approve therapeutic facet injections. You say that you are requesting an appeal for 
the enrollee's facet joint injections. The Plan denied your request. The Plan says the requested service 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 therapeutic facet injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there has not been diagnostic injection to determine whether there is facet 
generated pain. The source of the back pain in not known. Facet injection criteria 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 therapeutic facet injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the injections of lower or sacral spine facet joint using imaging guidance 
(64495, 64493 and 64494).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 ongoing care needs include respiratory support with tracheostomy care, 
hemodialysis, surveillance laboratory studies, tube feedings, and therapy services. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where they are currently receiving care. There are no required medical services identified that are 
available at the LTACH, that are not available at the current health care setting being offered by the health 
plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate 
for the diagnosis and condition of the enrollee at this time. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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 insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (CPT Code 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869) 
and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression 
or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires rehabilitation services in an IRF.The Plan denied your request. The Plan says IRF care 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 above.We asked our physician reviewer to carefully review the case file and apply therelevant 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 there is no documented evidence of medical issues that require monitoring by an inpatient rehabilitation physician three times a week. The documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care at the current functional status. She will not be able to make a significant functional recovery in a predicted period. In my opinion, an IRF admission is not medically necessary. The enrollee's needs can be met in an alternate, less intense 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute 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 fully electric hospital bed and full-length bed rails. 
 
You asked the Plan to pre-approve the fully electric hospital bed and full-length bed rails. You say that you 
would like reconsideration because the member can get out of bed and wander which may cause him to fall. 
The Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules also say that a total electric hospital bed is not covered. 
 
The items at issue in this appeal does not serve a purpose that is primarily medical in nature. The bed-rails are 
available to the general public and would be helpful even to those who are not sick or injured. Additionally, 
Medicare does not cover total electric hospital beds. Therefore, we decided that the Plan does not have to pre-
approve a fully electric hospital bed and full-length bed rails.