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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. You say you are unable to walk and care for yourself at home. You say you are getting 
dialysis treatment and have no support at home. The Plan denied your request. The Plan says the IRF services 
you 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 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of an oral appliance. 
 
You asked the Plan to pre-approve oral appliance. You say that the enrollee needs this to help breathing. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for this. 
 
The Plan follows Medicare rules. Medicare rules state that oral appliances may be covered if certain criteria are 
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 oral appliance. Our reviewer says that 
the enrollee does not meet criteria for this oral appliance. Our physician reviewer found the enrollee has mild to 
moderate obstructive sleep apnea and wishes to be fitted for an oral appliance. Medicare requires that a 
licensed dentist provide and bill for the device, but there is no evidence of this in the medical record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oral appliance have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of an oral appliance.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on October 21, 2022, billed with 
procedure codes 74230, 72040, 70100, 70310, and 74240. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the wrong place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another POS code exists.  
 We looked at the file and Medicare rules. Place of service 11 was billed, however the documentation does not 
support that the services were done in an office setting. Based on this information, we decided that Medicare 
rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have 
to pay for medical services provided on October 21, 2022, billed with procedure codes 74230, 72040, 70100, 
70310, and 74240.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this device is medically necessary. The Plan 
denied your request. The Plan says the requested device would be used in a bilevel positive airway pressure 
(BiPAP) mode that could be provided with a BiPAP device with average volume-assured pressure support 
(AVAPS) added to assure adequate tidal volumes. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the enrollee has Charcot-Marie-
Tooth syndrome and obstructive sleep apnea. The enrollee has used continuous positive airway pressure 
(CPAP) intermittently in the past, with successful treatment of the obstructive sleep apnea, but is poorly 
tolerant. The enrollee recently had an AVAPS titration study with transcutaneous CO2 monitoring.  The 
transcutaneous CO2 went up only slightly during rapid eye movement (REM) sleep. There are no pulmonary 
function tests or inspiratory mouth pressures to assess for diaphragmatic weakness. Therefore, there is no 
documentation that the enrollees neuromuscular disease has affected respiratory status or is causing significant 
hypoventilation during sleep. The obstructive sleep apnea is adequately treated with CPAP. 
 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve is a transcatheter aortic valve replacement 
(TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach (33361). 
 
You asked the Plan to pre-approve a TAVR. You say that the enrollee is symptomatic. The Plan denied your 
request. The Plan says the enrollee's valve is not as severe as required to meet criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when the criteria in the rules 
section of this letter are 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 a TAVR. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the enrollees aortic stenosis s moderate 
not severe. Thus, the enrollee does not meet criteria for coverage. 
 
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 TAVR have not been met. Therefore, we decided that the Plan does not have 
to pre-approve is a transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous 
femoral artery approach (33361).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need extensive rehabilitation to regain your 
independence. The Plan denied your request. The Plan says the requested IRF admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
at an intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing 
safety concerns and a potential for functional improvement however, the documentation does not support that 
you would meet criteria for admission to an IRF. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehabilitation 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E0955, 
E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, E2620). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you need this specific 
wheelchair because this is the only wheelchair that works for your body due to your medical condition. You 
have really bad spasms. You cannot have a normal wheelchair because it does not accommodate your medical 
condition. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 
wheelchair with power options. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you have left hemiplegia, not fully diagnosed for etiology. You do not 
use a catheter; you are not high risk for skin breakdown, and you have tremors, but no spasms found on a 
neurology exam. Per LCD L33789, the Medicare criteria for tilt or tilt and recline power drives are not met as 
stated above. No skin breakdown despite chronic impairment. No indication for an expanded controller and you 
have adequate upper body strength on the right. 
 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 and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E0955, E1007, E1012, 
E1028, E2300, E2311, E2313, E2361, E2377, E2607, E2620).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 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. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader device. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 reader device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the member does not use insulin with at least three 
daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. 
 
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 and 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 Freestyle 
Libre 2 reader device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 reader device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that this is the preferred supplier. The Plan denied 
your request. The Plan says the requested 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
durable medical equipment to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), although there 
are no pulmonary function tests, and has severe obesity. The enrollee has apparently had repeated 
hospitalizations with arterial blood gases showing acute on chronic Carbon dioxide (CO2) retention of varying 
severity. The enrollee was apparently provided with a trilogy ventilator on April 5, 2023 but was hospitalized 
again shortly thereafter. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. This 
enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure 
support (AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. Battery backup is not medically necessary. Therefore, the enrollee 
does not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 You asked the Plan to pre-approve Feraheme. You say that the requested drug is medically necessary for the 
enrollee's treatment. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drug, Infed. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred drugs. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred drugs. Therefore, the reviewer 
found that the step therapy criteria have not been 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration 
stating the enrollee meets all applicable criteria for admission to an IRF. The Plan denied your request. The 
Plan says the IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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 you are requesting an expedited reconsideration 
stating the enrollee meets all applicable criteria for admission to an IRF. The Plan denied your request. The 
Plan says the IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 the enrollee would meet criteria for admission 
to an acute inpatient rehabilitation facility. The enrollee 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.