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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's ability to regain maximum function is 
in jeopardy if denied the benefit of IRF. The Plan denied your request. The Plan says based on Medicare 
guidelines, the IRF services you and/or your provider are requesting 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 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 that the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollees functional status requires or can tolerate an 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Jet Spa/Whirlpool Pump. 
 
You asked the Plan to pre-approve a Jet Spa/Whirlpool Pump. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says a Jet Spa/Whirlpool Pump is not covered 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Jet Spa/Whirlpool Pump.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you were approved for 
dentures, but you cannot wear any metal in your mouth. The Plan denied your request. The Plan says this 
denture is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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-approve a 
mandibular partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthognathic surgical procedures including face bone 
grafting, lower jaw bone grafting, excision of tumor, excision of mandible lesion, and repair of tooth socket. 
 
You asked the Plan to pre-approve the oral surgery. You say that the enrollee's current resorptive pattern 
creates a functional deformity. You also say that failure to treat the enrollee could potentially result in many 
health issues. The Plan denied your request. The Plan says these services are dental in nature, and not 
appropriate for the orthognathic surgery codes as requested. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare also does not cover dental services, as defined 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 the oral surgery. Our reviewer says that 
the requested procedures are not considered medical in nature. Our physician reviewer found the requested 
procedures appear to be in regard to the care, treatment, filling, removal or replacement of teeth or structures 
directly supporting the teeth, rather than for the treatment of a medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the oral surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve orthognathic surgical procedures including face bone grafting, lower jaw bone 
grafting, excision of tumor, excision of mandible lesion, and repair of tooth socket.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested power wheelchair is not medically necessary. 
 
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 patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that the documentation does not support that the requested power wheelchair is medically reasonable or 
necessary. Our physician reviewer found the enrollee has arthritis, cognitive deficits, and chronic atrial 
fibrillation. The documentation indicates that the enrollee has 3+ left leg edema and poor abstract thinking. The 
enrollee has had repeated falls and recently fractured the left foot. The documentation does not support that the 
enrollee has the inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, 
or use of a walker). In addition, the documentation does not support that the enrollee can safely utilize a power 
wheelchair/scooter. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are equally qualified in-network plastic surgeons available to 
you that can provide the care and treatment you are requesting. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of lateral exostosis (D7471). 
 
You asked the Plan to pre-approve the removal of lateral exostosis. You say that your dentist says that this 
service is medically necessary. The Plan denied your request. The Plan says this service is not covered under 
your benefit package. 
 
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-approve a 
removal of lateral exostosis (D7471).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
You asked the Plan to pre-approve bathtub. You say that this tub would help improve your circulation, increase 
mobility, lessen pain, lessen chance of a slip or fall, and let you retain your independence. The Plan denied 
your request. The Plan says the denial of authorization for this item is correct, because walk-in tubs are not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Smart 150 Complete including suspension mechanical 
lift with electronic lift. 
 
You asked the Plan to pre-approve Smart 150 Complete including suspension mechanical lift with electronic 
lift. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan 
says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that electronic lifts are only covered for certain 
indications. 
 
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 Smart 150 Complete including 
suspension mechanical lift with electronic lift. Our reviewer says that the documentation does not support that 
the requested item is medically reasonable or necessary. Our physician reviewer found you have spinal muscle 
atrophy and are non-ambulatory and dependent with activities of daily living.  
You have had and used a mechanical lift for the past 7-8 years. The lift is now in poor condition as it shows 
signs of rusting and the hydraulic component is not reliable. The requested electronic lift does not meet 
medically necessary criteria per the LCD. Therefore, you do not meet criteria for the requested electronic lift. 
Your needs can be met adequately with a hydraulic lift. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Smart 150 Complete including suspension mechanical lift with electronic lift 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Smart 150 Complete 
including suspension mechanical lift with electronic lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal radiofrequency ablation of nerves supplying the 
sacroiliac joint with image guidance  (64625). 
 
You asked the Plan to pre-approve thermal radiofrequency ablation. You say that this same procedure was 
performed with good results in August of 2019. You are requesting a repeat of the same procedure which was 
successful in managing your pain for nearly a year. The Plan denied your request. The Plan says 
radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary and investigation 
whether performed using traditional, cooled or pulsed radiofrequency. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the thermal radiofrequency ablation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal radiofrequency ablation of nerves supplying the sacroiliac joint with image 
guidance  (64625).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex, interspinous and/or interlaminar device 
(22869). 
 
You asked the Plan to pre-approve the Vertiflex, interspinous and/or interlaminar device. You say that you 
believe that this is the most appropriate treatment for this enrollee and that this choice meets the requirements 
as being reasonable and medically necessary. The Plan denied your request. The Plan says this device is not 
covered by Medicare or the plan as medical studies have not proven that the device is helpful for treatment of 
your health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex, interspinous and/or interlaminar device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Vertiflex, interspinous and/or interlaminar device (22869).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Esomeprazole Magnesium. 
 
You asked the Plan to pre-approve Esomeprazole Magnesium. The Plan denied your request. The Plan says this 
drug is not covered under the enrollee's Part B 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 Esomeprazole Magnesium.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880). 
 
You asked the Plan to pre-approve the duplex scan. You say that you would like reconsideration because the 
hospital is in-network with the Plan. The Plan denied your request. The Plan says this provider has opted-out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal are non-urgent and non-emergent. This provider has opted out of the 
Medicare program. The record indicates that there are in-network providers available to render the service at 
issue. Therefore, we decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries 
(93880).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lanreotide injections to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON lanreotide injections. You say that the enrollee has been seeing this 
doctor for two years. The Plan denied your request. The Plan says these services are available in-network. 
 
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 
the lanreotide injections to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allowance for food items, electricity, bill payments, 
etc. (S9986). 
 
You asked the Plan to pre-approve the allowance. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. The requested code, S9986, is assigned a status indicator of 'I' under 
the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. The requested 
services are not covered by Medicare, and therefore are not covered under your plan. Therefore, we decided 
that the Plan does not have to pre-approve an allowance for food items, electricity, bill payments, etc. (S9986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that you are appealing based on the 
enrollee's sugar levels. The Plan denied your request. The Plan says the denial of authorization for this device is 
correct, because the enrollee is not on multiply daily insulin injections. 
 
The Plan follows Medicare rules. Medicare rules say that a therapeutic continuous glucose monitor is covered 
when all of the above listed clinical criteria have been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continuous glucose monitor. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested continuous glucose 
monitor. Our physician reviewer found the enrollee is not on insulin therapy, therefore the enrollee does not 
meet all of the criteria for coverage of a continuous glucose monitor. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous glucose monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics provided by a specific provider. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are unable to walk without orthotics. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics provided by a specific provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed your 
benefit limit. 
 
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 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Review of the file shows that you have 
currently used 23 of your 24 allotted plan approved one-way trips. Based on this information, we decided that 
once you use your last plan approved one-way trip, you will 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says rules for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM's are covered when the beneficiary is 
insulin-treated with multiple (three or more) daily injections of insulin.  
 
We looked at the file and Medicare rules. The enrollee does not use insulin. Based on this information, we 
decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. foot orthotics shoe inserts. You say that you are unable to 
walk or stand without extreme discomfort. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.