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

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260) and patient lift 
(E0630). 
 
You asked the Plan to pre-approve a semi-electric hospital bed and patient lift. You say that the items are 
necessary. The Plan denied your request. The Plan says the requested items are not more than 5 years or 
irreparable. Therefore, coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). Replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a semi-electric hospital bed and patient lift have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a semi-electric hospital bed (E0260) and patient lift (E0630).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to carry over your quarterly allowances for over-the-counter (OTC) 
items from the first two quarters of 2022. 
 
You asked the Plan to carry over OTC benefits from previous quarters. You say that you would like to be able 
to use your over-the-counter benefit allowances for the first two quarters of 2022 because you were not aware 
of the benefit at the time. The Plan denied your request. The Plan says your quarterly allowance for over-the-
counter items cannot be carried over into another quarter. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover OTC items. However, the 
Plan offers a benefit which exceeds Medicare coverage. The Plan covers up to $75 for certain OTC items each 
quarter. Quarterly allowances cannot be carried over into another quarter. Therefore, we decided that the Plan 
does not have to carry over your quarterly allowance for OTC items from the previous quarters.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory insulin infusion pump (E0784). 
 
You asked the Plan to pre-approve an insulin infusion pump. You say that the enrollee needs an insulin pump 
to keep their blood sugar at a normal range. The Plan denied your request. The Plan says this request is not 
medically necessary because the records show the enrollee does not have evidence of a low c-peptide level in 
conjunction with a fasting blood glucose of less than 225. The Plan also says that the enrollee has not 
participated in comprehensive diabetes education, and it was stated the enrollee is not a good candidate for the 
insulin pump. 
 
The Plan follows Medicare rules. Medicare rules say if criterion A or B listed in the Medicare rules section of 
this letter is not met, and criterion C or D listed in the Medicare rules section of this letter is not met, the pump 
and related accessories, supplies, and insulin will be denied as not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an insulin infusion pump. Our reviewer 
says that an insulin infusion pump is not medically reasonable and necessary for the enrollee. Our physician 
reviewer found the enrollee has type 1 diabetes and has a low C-peptide, but there is no simultaneous 
corresponding fasting blood sugar. The record does not indicate that the enrollee has completed a 
comprehensive diabetes education program. Our reviewer found that the provider has noted that the enrollee is 
a not a good candidate for an insulin pump. The elements of the coverage criteria are not satisfied. Our 
physician reviewer also found that the requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an insulin infusion pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external ambulatory insulin infusion pump (E0784).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel that this IRF care is the best option. The 
Plan denied your request. The Plan says your needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted to the hospital due to a chronic right foot wound requiring 
below-the-knee amputation. The most recent therapy notes indicate that the enrollee requires a walker and contact guard assistance to hop and is able to accomplish transfers with minimal assistance. 
 
In this case, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute 
rehab 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, at an 
intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. You 
continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that you would meet criteria for admission to an 
acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an 
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain your functional status. You can receive further services 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease pathogen study (including COVID-19) 
(0202U) provided on April 5, 2022. 
 
You asked the Plan to pay for the respiratory pathogen panel. You say that this is a covered service which 
should be paid. The Plan denied your request. The Plan says this service is not covered, and it is not clear how 
the enrollee came to this provider from the documentation provided. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0202U is a non-covered service/code. 
Based on this information, we decided that Medicare rules for coverage of the respiratory pathogen panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the infectious disease pathogen 
study (including COVID-19) (0202U) provided on April 5, 2022.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the admission and care are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission is not medically reasonable or 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that he would meet criteria for admission 
to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain his functional status. He can receive further services 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that due to the current level of discomfort 
with your current wheelchair, your controller is starting and stopping. You have had the same cushion for 5 
years and it needs replacing. It is causing some lower back and buttocks pain. The Plan denied your request. 
The Plan says the requested accessory is not covered because it is not primarily medical in nature. 
 
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 power seat elevation system (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is a medical necessity. The 
Plan denied your request. The Plan says the enrollee does not meet long-term acute care hospital admission 
criteria. 
 
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 was admitted to the hospital on September 6, 2022, with a diagnosis of 
sigmoid diverticulosis with an intra-abdominal abscess. The enrollee was treated medically and surgically with 
a sigmoid colectomy with a colostomy. The enrollee has improved but continues to require care in an acute 
care setting. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where they are currently receiving care. The enrollee has improved medically and can receive further 
care at the current facility or a lower level of care when deemed appropriate. 
 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 the 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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have 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 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 pain is the primary limiting factor for your condition. You do not have 
impairment in your arms, or your legs and you have no spasticity or contractures. You have no significant head injury or behavior disturbances and are walking 50 feet minimum. In this case, your care needs are consistent 
with uncomplicated post-acute care rehabilitation. You do not require intensive rehabilitation to achieve your 
rehabilitation goals and have has no complexity requiring frequent physiatry oversight. Your care needs do not 
require an IRF admit to reasonably achieve your goals. 
 
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 the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure fills a treatment gap for 
patients that do not receive adequate relief from traditional conservative methods. You say that the Intracept 
procedure is medically necessary, and the denial is unwarranted. The Plan denied your request. The Plan says 
this procedure is considered experimental and investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance for a continuous glucose monitor 
(CGM) and oral cushion comb oral/nasal mask (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM supply allowance and oral cushion comb. You say that you had a 
heart attack in the past and you are currently on medication for that. The Plan denied your request. The Plan 
says your request is not medically necessary because your records show you do not have a need to administer 
insulin three or more times daily with frequent variation in dosing. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM 
supply allowance and oral cushion comb have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a supply allowance for a continuous glucose monitor (CGM) and oral cushion comb oral/nasal 
mask (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guidance for radiation therapy (CPT code 
G6001). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is not enough medical evidence to show that this type of radiation treatment 
guidance using ultrasound is needed or effective to treat the enrollee's skin cancer. 
 
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 billing for daily simulations (also requested in this case) or image-guided radiation therapy 
(IGRT) would not be furnished in accordance with accepted standards of medical practice". 
 
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 ultrasound guidance for radiation therapy (CPT code G6001).
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 the requested services are medically 
necessary. The Plan denied your request. The Plan says the LTACH admission 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 the provided documentation indicates that you are receiving appropriate care at the 
present acute care hospital. The reviewer found that you do not require services at the LTACH that are not 
available at the acute care hospital where you are currently receiving care. Therefore, the reviewer found that 
the requested LTACH care is not medically reasonable or 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 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.