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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD) with 2 recent 
hospitalizations for acute on chronic hypercarbic respiratory failure. This enrollee clearly has chronic carbon 
dioxide (CO2) retention. The enrollee responded to bilevel positive airway pressure (BiPAP) in the hospital, 
along with other treatments. The enrollee would likely benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient. But Medicare does not cover a home ventilator when 
used with settings that can be provided by BiPAP, at less cost to the enrollee. 
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has complex medical needs 
that require physician oversight as well as skilled therapy. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee's care needs can be provided in current 
inpatient setting. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The health plan has approved ongoing care in the current 
acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ongoing skilled physical therapy (PT) 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 clinical documentation does not show that ongoing skilled PT services are needed to 
provide services to restore function or to prevent deterioration. 
 
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 the services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The requested services are not medically reasonable or necessary. Our physician reviewer found that 
the additional requested therapy generally is not accepted as specific and effective therapy for the patients 
condition beyond what was approved by the health plan. The patient has had prior therapy and the 
documentation does not reveal that the patient's requires the unique skills of a professional therapist to safely 
and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, 
or by or under the supervision of a therapist.  The requested services are not part of a maintenance program, 
and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
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 ongoing skilled physical therapy (PT) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Health Plan. The Health Plan has approved ongoing 
care in the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine pad. 
 
You asked the Plan to pre-approve Lidocaine pad. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Lidocaine pad.  
 
Benefits for Lidocaine pad 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 Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this service is helpful. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that clinical documentation supports your 
request. The Plan denied your request. The Plan says the request 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (E2300), hand or chin 
control interface joystick (E2374), electrical assy mounting bracket, Q-logic 3, fender light module, harness, 
electronic box, joystick receiver (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that all of the components described are 
medically necessary to ensure optimal postural alignment and support in the power wheelchair as he lacks the 
volitional control due to this T3 complete paraplegia resulting from his spinal cord injury. The Plan denied 
your request. The Plan says you do not meet coverage criteria for the requested wheelchair accessories. 
 
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 wheelchair accessories. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the requested power wheelchair accessories at issue in this case meet 
all Medicare criteria for medically reasonable and necessary for you. The requested power seat elevation 
feature is statutorily non-covered as it serves no primary medical purpose. The requested fender light module is 
statutorily non-covered as it serves no primary medical purpose. Provided records do not document that the 
patient's current joystick cannot be used. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve power seat elevation system (E2300), hand or chin control interface joystick 
(E2374), electrical assy mounting bracket, Q-logic 3, fender light module, harness, electronic box, joystick 
receiver (K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is a lack of documentation to support the need for a physical therapist. 
 
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 the additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The requested visits are not medically reasonable or necessary. Our physician reviewer found that in 
this case, the enrollee has previously been treated with outpatient therapies and should be independent with a 
home exercise program. There is no documentation of a recent injury or decline in function. The additional 
therapy services are not an appropriate duration and frequency for treatment of the enrollees medical condition 
and therefore are not medically 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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E1002, 
E2311, E1012). 
 
You asked the Plan to pre-approve the features. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met for these features. 
 
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 features. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient is not at high risk for skin breakdown, no evidence of spasticity or intermittent 
catheterization. Therefore, the request for power tilt is not medically necessary. The E2311 is not medically 
necessary as the patient's strength and function are sufficient to control the power options through their own 
switches. There is no evidence of significant lower extremity edema. There is no evidence of a condition, cast, 
or brace preventing 90 degree knee flexion. The requested power elevating leg rests are not medically 
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 features have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E1002, E2311, E1012).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not good to go home and are at risk of 
falling. You say that you live by yourself and have no one to take care of you. The Plan denied your request. 
The Plan says a SNF admission is not medically necessary, and you can safely receive the service you need in 
other settings. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you have identifiable skilled nursing service needs but does not have identifiable 
skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis as an 
inpatient in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with Auto-EPAP 
(AE) that could be delivered by BiPAP is not covered. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that in this 
case, the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary 
disease. The record indicates that the enrollee was successfully treated with BiPAP. The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has 
indicated coverage for such a device is available upon request. The elements of the coverage criteria are not 
satisfied. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with accessories/features/power 
options. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no need for the power option included with the requested power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is 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 the services. Our reviewer says that the 
requested wheelchair is medically reasonable or necessary. Our physician reviewer found that you have 
Parkinsons disease with impaired mobility due to weakness, bradykinesia, and rigidity. You are unable to 
safely ambulate and therefore cannot use a walker for assistance with ambulation. You require maximum 
assistance with ambulation and are at high risk for falling. You cannot independently transfer and does not 
have the coordination to operate a power scooter. You require a power wheelchair for mobility and 
accomplishing his daily activities. You require a power wheelchair with power tilt and recline since you are 
unable to perform pressure relief independently due to upper extremity weakness and rigidity as well as 
decreased shoulder range of motion. You are at risk for skin breakdown given his lack of ability to perform 
pressure relief and independently transfer. You also require power elevating leg rests given your positioning 
needs and limited range of motion and rigidity in your lower extremities. Because you require the power 
components, you require a group 3 power wheelchair.  It is documented that you can safely operate a power 
wheelchair and are noted to have the hand strength to operate a joystick. Therefore, the group 3 power 
wheelchair is medically 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 services have been met. Therefore, we decided that the Plan has to pre-approve a group 3 power wheelchair 
with accessories/features/power options.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 11, 
2022, to April 28, 2022. 
 
You asked the Plan to pay for SNF care. You say that you feel that you should not have to pay for the time that 
the enrollee was kept for no reason. The Plan denied your request. The Plan says the services received by the 
enrollee were not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was walking household distances with a wheeled walker with contact 
guard assistance and was contact guard assist for transfers. There is no documentation that the enrollee required 
skilled nursing services or skilled therapy services for the dates of service at issue. Therefore, the enrollee did 
not meet criteria for the SNF services provided April 24, 2022, to April 28, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. The Plan has paid for the services received 
from April 11, 2022, to April 23, 2022 with no enrollee responsibility. Based on this information, we decided 
that Medicare rules for coverage of SNF care received from April 24, 2022, to April 28, 2022 have not been 
met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided 
from April 11, 2022, to April 28, 2022.