Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you $250 for the acupuncture services (97810) provided from 
January 7, 2021, to December 30, 2021. 
 
You asked the Plan to reimburse you $250 for the acupuncture services. You say that you were advised you 
would receive reimbursement 60 days after it was received. You also say that you sent all of the necessary 
paperwork that was required on March 11, 2022. The Plan denied your request. The Plan says that the 
reimbursement request was not received by March 31, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not support that the Plan received the reimbursement 
request after March 31, 2022. Therefore, we decided that the Plan has to reimburse you $250 for the 
acupuncture services (97810) provided from January 7, 2021, to December 30, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories/features. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no need for this requested group 3 power wheelchair with the requested power 
options/features. 
 
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 the services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not indicate that you have any pressure injuries or requires intermittent catheterization of 
the bladder that would necessitate power tilt. Although criteria are met for a power wheelchair, the 
documentation doesn't support the medical necessity for the requested power wheelchair with power tilt. 
 
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 a group 3 power wheelchair with accessories/features.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric bone growth stimulator. 
 
You asked the Plan to pre-approve an electric bone growth stimulator. You say that a bone growth stimulator is 
medically necessary. The Plan denied your request. The Plan says the patient does not meet criteria for this 
item because there is no clinical documentation of a nonunion of a long bone fracture. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 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 electric bone growth stimulator. Our 
reviewer says that an electric bone growth stimulator is not medically necessary. Our physician reviewer found 
the patient is a 67-year-old female with a non-displaced fracture of second, third, and fourth metatarsal bone. 
She was treated with cam walker. Imaging shows healing without dislocation or suggesting of nonunion. A 
request was made for a bone growth stimulator. However, there is no clinical documentation of a nonunion of a 
long bone fracture for at least 3 months, as required. Therefore, this request for a bone growth stimulator is not 
medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electric bone growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electric bone growth stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental healthcare. 
 
You asked the Plan to pre-approve continued inpatient mental healthcare. You say that continued care will 
make the enrollee's discharge safer. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued inpatient mental healthcare. Our reviewer says that the requested inpatient care is not medically necessary at this time. Our physician 
reviewer found the records do not show that the enrollee is a danger to herself or others. There are not 
delusions or hallucinations documented. She has been cooperative and compliant with treatment while not 
showing any threats to her own or others' safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient mental healthcare have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient mental healthcare.
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 that the enrollee is not safe in their home setting, and 
a discharge to a lower level of care would jeopardize their ability to return home within a reasonable amount of 
time. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the 
enrollee can safely receive the services they need in the current hospital setting. 
 
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 enrollees 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: Favorable

 
We decided that the Plan has to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the enrollee 
medically needs the mattress. Without the mattress, it would cause a lot of complications to the enrollee's 
health. The Plan denied your request. The Plan says that the requested mattress does not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 a powered pressure-reducing air 
mattress. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a large stage IV ulcer and functional 
paraplegia. There is evidence the enrollee is receiving an appropriate treatment plan from a wound center. 
 
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 powered pressure-reducing air mattress have been met. Therefore, we decided 
that the Plan has to pre-approve a powered pressure-reducing air mattress (E0277).  
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis. 
 
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough medical evidence that shows that this device is reasonable and 
necessary to improve the function of the left arm. 
 
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 orthosis. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the requested device is used for the upper extremity. It is an arm brace that is motorized 
and can help an individual with upper extremity weakness to move their arm and hand. The requested device 
has not been shown to be superior to other standard treatments for the medical condition. The studies do not 
indicate the MyoPro brace improves an individuals function or general health. The requested device is 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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral device/appliance used to reduce upper airway collapsibility 
(K1027). 
 
You asked the Plan to pre-approve an oral device/appliance. You say that the current CPAP you have is greatly 
aggravating your allergies and causing disturbances in your sleep. You do not want to undergo surgery as you 
have issues with blood clots. The Plan denied your request. The Plan says that the requested appliance is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 oral device/appliance. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found you have severe OSA, with AHI of 47 on a sleep test within the past year. You are 
intolerant of CPAP. There is a history of stroke, and you are taking clopidogrel, and are reluctant to have 
surgery for this reason, precluding treatment with the hypoglossal nerve stimulator.  The Slow Wave DS8 is 
FDA approved for mild to moderate OSA, as are other oral appliances. However, you do not have other 
alternatives.  You may benefit from this device even if the sleep disordered breathing is only partially treated. 
 
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 oral device/appliance have been met. Therefore, we decided that the Plan has 
to pre-approve an oral device/appliance used to reduce upper airway collapsibility (K1027).  
 
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: 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 care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF), outpatient setting or 
home health care. The Plan denied your request. The Plan says the enrollee is falling at home and home health 
care is not efficient. 
 
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 for rib fractures after a fall and was discharged home on 
October 30, 2022, with ongoing weakness. The enrollee's medical problems are stable, and there are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that this drug is necessary for the enrollee. The Plan 
denied your request. The Plan says this medication may be covered under Part B if it is being administered with 
cancer chemotherapy treatment that is initiated within 2 hours of the administration of chemotherapy. The Plan 
also says that this drug is not covered under Medicare Part B. 
 
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. The provided documentation does not support that the requested drug would be used within 2 
hours of chemotherapy administration. Therefore, we decided that the Plan does not have to pre-approve 
Ondansetron.   
Benefits for Ondansetron 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: 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 sending you to a nursing home will keep you 
unhealthy and sick, while with the inpatient rehab you can get better and thrive again. You say that you can 
regain the independence you had before with admission to an IRF. The Plan denied your request. The Plan says 
an IRF admission is not medically necessary, and your needs can be met at an alternate 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 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: 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 enrollee requires ventilator support, 
and the enrollee requires LTACH level of care for safe ventilator weaning and to give her optimal chance at 
recovery. The Plan denied your request. The Plan says the LTACH is not medically necessary, and the 
enrollee's needs can be met at another setting such as an acute rehabilitation facility, skilled nursing facility, 
nursing facility, outpatient setting or home care. 
 
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 acute inpatient setting for treatment of acute 
respiratory failure requiring intubation and mechanical ventilation. The enrollee had a tracheostomy and has 
continued to require ventilator support. There is no documentation provided indicating medical necessity for 
admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 
 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.
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 your doctor recommended that you would need three 
hours a day of intensive physical and occupational therapy. You say the SNF only provides one hour a day of 
therapy. 
 The Plan denied your request. The Plan says the IRF care is not medically necessary, and your needs can be 
met at a lower level of care such as a skilled nursing facility (SNF), outpatient setting, or home health 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 you were admitted for surgical repair of a hip fracture after a fall. Your medical 
problems are stable, and there are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. 
 
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.