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

 
We decided that the Plan has to pre-approve continued ventilator services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says that the 
enrollee did not have adequate usage. 
 
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. 
 
We looked at the file and the rules. The Plans denial for coverage was based on guidelines found in Local 
Coverage Determination, L33880, for respiratory assist devices. The coverage criteria of usage for an average 
of four hours per day on seventy percent of days, is for a respiratory assist device with bi-level pressure 
capability (code E0470 and E0471), and not the ventilator (E0466) at issue. The Plan has not made reasonable 
and diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pre-approve continued ventilator services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the x-ray provided on November 28, 2022. 
 
You asked the Plan to waive the deductible for the x-ray. You say that this service is preventative and should 
not be subject to the deductible. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to outpatient diagnostic tests and 
therapeutic services. Your contract with the Plan also clearly says that you must pay 20% coinsurance after 
meeting your deductible for outpatient diagnostic tests. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $250 deductible which applies to outpatient diagnostic tests and therapeutic services. 
This cost sharing is a contractual obligation that had not been met at the time the x-ray was received on 
November 28, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the x-ray 
provided on November 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen. 
 
You asked the Plan to pre-approve Privigen. 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 follows Medicare rules. Medicare rules say that IVIG is covered for certain conditions. 
 
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 Privigen. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee's diagnosis of an autoimmune 
neuropathy is not one for which the LCD provides coverage of IVIG. Nor is the enrollee's diagnosis one for 
which the use of IVIG is otherwise supported within the Medicare approved Compendia. This would therefore 
not meet requirements 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 Privigen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Privigen.
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 LTACH services. You say that the enrollee is ready for discharge from the 
acute care hospital and would benefit from an admission to an LTACH to regain a maximum/prior level of 
functioning and to continue a multidisciplinary approach to care. The Plan denied your request. The Plan says 
the enrollee's medical needs can be met in the current 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care setting. 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 Plan. The Plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 7, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your 
request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 7, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle, symes, molded socket, sach foot (L5050), an 
addition to lower extremity, test socket, symes (L5618) and an addition to lower extremity, symes type, 
posterior opening socket (L5634). 
 
You asked the Plan to pre-approve ankle and foot prosthetics. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the requested items exceed your need and does not meet the Medicare 
criteria of reasonable and necessary. 
 
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 ankle and foot prosthetics. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have a partial mid-foot amputation on the left and you require a partial 
foot prosthesis with a carbon plate. You have a right below knee amputation as well. You do not have a Syme's 
amputation. The requested prosthesis is for a Syme's amputation which you do not need. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ankle and foot prosthetics have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an ankle, symes, molded socket, sach foot (L5050), an addition to lower 
extremity, test socket, symes (L5618) and an addition to lower extremity, symes type, posterior opening socket 
(L5634).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair (K0861) and the 
other requested items/ accessories (codes E2311, E2377, E2313, E1007, and E1012). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and other items/accessories. You say 
that the request for group 3 complex power wheelchair is necessary with all the requested components, and is 
necessary in every aspect of the enrollee's life. You also say that without this exact configuration, the enrollee 
is not only unable to ambulate, but they are also at a high risk for pressure injuries. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for tilt feature and therefore does not meet for the 
base code group 3 power wheelchair with multiple power options. The Plan also says there is not a medical 
need to control the power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 standard power wheelchair 
and other items/accessories. Our reviewer says that the enrollee does not meet the criteria for coverage for a 
group 3 standard power wheelchair and accessories. Our physician reviewer found the enrollee does not require 
the tilt or tilt recline feature as they do not have high risk for skin breakdown, use a catheter, or have spasticity. 
Our reviewer found that therefore, the group 3 powered wheelchair cannot be covered. 
 
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 group 3 standard power wheelchair and other items/accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power wheelchair 
(K0861) and the other requested items/ accessories (codes E2311, E2377, E2313, E1007, and E1012).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial ostectomy, and the collection and application of 
autologous blood concentrate product (D7550, D7921) provided on November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a partial 
ostectomy and the collection and application of autologous blood concentrate product (D7550, D7921) 
provided on November 2, 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 enrollee needs to be assessed both medically and 
functionally in regard to their premorbid functional capacity to determine whether they can benefit from a 
rehabilitation level of care offered The Plan denied your request. The Plan says the records does not show the 
enrollee needs an intensive team for care, services needed can be provided safely in other settings, a skilled 
nursing facility, home with home health services or home with outpatient therapy. 
 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 is deconditioned secondary to seizure, acute hospital stays and substance 
abuse, has no barriers to rehabilitation training and does not require frequent physiatry oversight or complex 
services. His needs may reasonably be met at a level of care other than 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 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 a Barostim NEO device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee failed medical therapy. The 
Plan denied your request. The Plan says experimental procedures are not covered. 
 
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 requested services. Our physician 
reviewer found that the enrollee has symptoms thought due to chronic systolic heart failure (CHF) despite 
medical management, in the setting of severely reduced left ventricular function. Baroreflex stimulation 
devices have been considered potential alternative treatments for resistant hypertension and heart failure. There 
remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not 
be considered medically reasonable and necessary in this enrollees clinical management. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim NEO device.
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 services are necessary for the 
enrollee to receive the care needed. The Plan denied your request. The Plan says all services that would be 
provided in the long-term acute care hospital are being provided in the current acute care setting which is 
already approved. 
 
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. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sit to stand table system with a seat lift feature. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the item 
is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We looked at the file and the rules. The item at issue in this appeal does not serve a purpose that is primarily 
medical in nature. This item 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 sit to stand table system with a seat lift feature.
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 SNF is not equipped to handle the 
enrollee's needs. The enrollee needs a transfusion every one to two days and will only get one transfusion a 
week in a SNF. The Plan denied your request. The Plan says the LTACH is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 with cute on chronic hypoxic respiratory failure in the 
setting of sepsis secondary to multifocal pneumonia of acute on chronic diastolic heart failure. The record indicates that the enrollee is improving but still requires acute care services before transitioning to 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames, the progressive lens, the scratch resistant 
coating, the ultraviolet (UV) lens, the anti-reflective coating, and the tint provided on November 18, 2022.  
You asked the Plan to pay for the vision items. You say that the benefit is $300 per year and there should be 
$140.02 left on the benefit. The Plan denied your request. The Plan says the benefit limit was exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once a year. 
 
We looked at the file and the Plan's rules. Specifically, you received one pair of standard lenses and frames on 
November 17, 2022, which exhausted the benefit. Based on this information, we decided that the Plan's rules 
for coverage of the vision items have not been met. Therefore, we decided that the Plan does not have to pay 
for the deluxe frames, the progressive lens, the scratch resistant coating, the ultraviolet (UV) lens, the anti-
reflective coating, and the tint provided on November 18, 2022.
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 care that includes a 
multidisciplinary team and daily services to have the best outcome. The Plan denied your request. The Plan 
says all services that would be provided in the LTACH are being provided in the current acute care setting 
which is already approved. 
 
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. 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 long term acute care hospital (LTACH) 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 services are necessary for the 
enrollee to prevent readmission and reach the goal of going into a lower level of care. The Plan denied your 
request. The Plan says the enrollee's care can be provided in the current inpatient hospital. 
 
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. 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 long term acute care hospital (LTACH) services.