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

 
We decided that the Plan does not have to pre-approve power wheelchair accessories (power seat elevation, 
expandable controller, harness, electrical connection). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says these items are not needed. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that you require other types of proportional input devices 
(e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional 
input devices (e.g., sip and puff, head array, etc.). You do not need to operate 3 or more powered seating 
actuators through the drive control, a  separate display (i.e., for alternate control devices),other electronic 
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an 
attendant control. Your strength and functional ability of self feeding in the left upper limb are sufficient to be 
able to control any power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. The power seat elevation system is not 
covered, as it does not serve a primarily medical purpose. Our doctor found that that the other accessories are 
not needed as well. Based on this information, we decided that Medicare rules for coverage of the accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair 
accessories (power seat elevation, expandable controller, harness, electrical connection).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device. 
 
You asked the Plan to pre-approve a power mobility device. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be rendered by the out of 
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are providers available in-network to render 
the requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
medical services to be rendered by the out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical 
history of Crohn's disease who is being treated in an acute inpatient rehabilitation facility for a traumatic brain 
injury/left intraparenchymal hemorrhage. She is weak and deconditioned and is working with physical, 
occupational and speech therapy but she is not making significant progress and discharge from the acute 
inpatient rehabilitation facility is being contemplated. She is not walking due to impaired balance, posture, 
motor control and strength. She is maximum assist for transfers and most activities of daily living; she is 
dependent for bathing and toileting. She is medically stable. 
 
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 is not required to 
safely and effectively provide medically necessary and reasonable treatment. Based on the medical records 
provided this enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment 
of a qualified therapist is required to safely and effectively provide medically necessary and reasonable 
treatment. Based on the medical records provided daily skilled services are not required. Based on the medical 
records provided this enrollee does not require the services on 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says the enrollee's plan 
does not cover outpatient prescription drugs. 
 
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 Eliquis.  
 
Benefits for Eliquis 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the requested Vertiflex device is 
medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 the Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is 
with spinal stenosis. The device is experimental. More research is need to show the safety and efficacy of the 
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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted for left 
knee surgery on 9/16/20. From a nursing perspective, the enrollee received oral medications. The enrollee had 
stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the enrollee received 
physical therapy in the acute hospital. The enrollee was at a modified independent to independent level with 
functional mobility including gait to 250 feet x 2.   
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kyphoplasty of L3 and L4 vertebral bodies. 
 
You asked the Plan to pre-approve Kyphoplasty of L3 and L4 vertebral bodies. You say that the requested 
Kyphoplasty of L3 and L4 vertebral bodies is medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for the requested Kyphoplasty of L3 and L4 vertebral bodies. 
 
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 Kyphoplasty of L3 and L4 vertebral 
bodies. Our reviewer says that the enrollee does not meet criteria for the requested Kyphoplasty of L3 and L4 
vertebral bodies. Our physician reviewer found the enrollee is with a diagnosis of multiple myeloma. There is 
no clear documentation of new pathologic spine fractures. There is no imaging study showing severe 
pathologic spine fracture. More information is needed to justify the role of kyphoplasty. It is not needed 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 Kyphoplasty of L3 and L4 vertebral bodies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Kyphoplasty of L3 and L4 vertebral bodies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that you are appealing the 
decision regarding medical necessity for physical therapy. The Plan denied your request. The Plan says 
additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that you have had therapy since February 27, 2020 
and were trained in a home exercise program. Our reviewer says that the unique skills of a professional 
therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of 
SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for continuation of SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a 
past medical history of hypertension who was admitted to a skilled nursing facility on 09/04/2020 for 
rehabilitation after a fall with a closed head injury and a left inferior pubic ramus fracture. She has left sided 
weakness and is unsteady and has been working with physical and occupational therapy in the facility. She is 
walking with minimum assistance with a quad cane and is minimum assist for transfers and minimum to 
moderate assist for activities of daily living. She is medically stable. 
 
Based on the medical records provided there is no documentation that the enrollee requires skilled nursing 
services. Based on the medical records provided this enrollee does not require skilled therapy services. Based 
on the medical records provided daily skilled services are not required. Based on the medical records provided 
this enrollee does not require the services on 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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod Dash (A9274). 
 
You asked the Plan to pre-approve the Omnipod Dash. You say that disposable pumps are not covered under 
Medicare Part B, but are covered under Medicare Part D. You also say that the enrollee needs the ability to 
have multiple basal rates to avoid hypoglycemia and to get to their target blood glucose levels. The Plan denied 
your request. The Plan says this is not covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps are non-covered devices because they do not meet the Medicare definition of 
durable medical equipment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Omnipod Dash have not been met. Specifically, this item is not covered by the Plan or by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve an Omnipod Dash (A9274).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you need this denture because 
your original denture was accidentally thrown in the trash. You also say that you are having trouble chewing 
food and are not able to eat a full meal. The Plan denied your request. The Plan says this service exceeds the 
maximum count allowed per period. 
 
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, mandibular partial denture (D5214) is 
limited to one procedure every five plan years. The record shows that you received a mandibular partial denture 
on October 12, 2018 and your mandibular partial denture benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's current needs do not appear to be skilled in nature. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the records do not 
show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to 
improve your condition, or to establish/perform a maintenance program to maintain the patient's condition 
and/or prevent deterioration. Your wound care needs are not complex and do not require the ongoing needs of 
ongoing home health SN. You had received education in his wound care needs and medications. You are able 
to drive and follow up outpatient to the wound clinic for close monitoring. 
 
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 home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee 
is medically stable with no intent to harm self or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued inpatient services beyond September 17, 2020, were requested 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 continued services. Our physician reviewer found that active treatment was 
not taking place. The services were not reasonably expected or medically necessary to improve your condition, 
or for the purpose of diagnosis. The services were supervised and evaluated by a physician. Based upon review 
the records, you could be treated in a lesser restrictive setting as you were not showing any suicidal or 
homicidal ideation, auditory or visual hallucinations, or delusions. You were not showing any behaviors or 
aggression. You were cooperative and compliant, while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient mental health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brand specific power operated vehicle. 
 
You asked the Plan to pre-approve the brand specific power operated vehicle. You say that your current scooter 
is too large and too fast. The Plan denied your request. The Plan says your current power operated vehicle is 
considered appropriate for your condition. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power operated vehicle provided on July 6, 2020. The power operated vehicle 
provided on July 6, 2020 serves the same purpose as the brand specific power operated vehicle at issue. Your 
POV is still within the 5-year RUL and the documentation submitted does not show that your POV is 
irreparably worn, irreparably damaged, or that you have had a change in medical condition to warrant the 
scooter at issue. Based on the records provided, there is no indication that a replacement POV meets Medicare 
coverage criteria. Medicare coverage criteria for a POV replacement were not met. Therefore, we decided that 
the Plan does not have to pre-approve the brand specific power operated vehicle.