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

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the power wheelchair and accessories 
are not medically necessary. 
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee does not have the conditions which warrant multiple power drives. The enrollee can manage the standard 
switches and does not require alternative means of managing her power wheelchair. The enrollee is not at high 
risk for skin breakdown. As the PWC base is not medically necessary, the requested accessories are not 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) and accessories.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care after April 14, 2023. 
 
You asked the Plan to pre-approve SNF care after April 14, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says that the continued admission to a 
SNF is 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 pre-approve SNF care after April 14, 2023. Our 
reviewer says that the requested SNF care is considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the documentation shows that the enrollee has acute 
clinical/functional status change thus required skilled nursing/therapy assessment. Evaluating therapists 
recommend continued skilled therapies in current SNF setting, skilled nursing providing dysphagia care and 
pain management, baseline modified independent with mobility. 
 
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 after April 14, 2023, have been met. The Plan must continue coverage 
for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has 
been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-
approve continued skilled nursing facility (SNF) care after April 14, 2023.  
 
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 pay for the acute inpatient hospital care provided from May 22, 
2022, to May 23, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the 
inpatient care was not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from May 22, 2022, to May 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulation (PNS) system 
(64555, 76942). 
 
You asked the Plan to pre-approve the Sprint PNS system. You say that the denial for this procedure is 
unwarranted and unsupported. This procedure is medically necessary for the enrollee. The Plan denied your 
request. The Plan says there is insufficient medical literature to support the use of the SPRINT PNS system for 
chronic shoulder pain. 
 
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 Sprint PNS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Sprint PNS device is experimental for shoulder pain.  
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 Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Sprint peripheral nerve stimulation (PNS) system (64555, 76942).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Stimwave peripheral nerve stimulator (PNS) system 
(64590, L8680, L8683, and 64555). 
 
You asked the Plan to pre-approve the Stimwave PNS system. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically 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 the Stimwave PNS system. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient evidence in the medical literature supporting the use of an 
implanted neurostimulator device for the treatment of chronic knee pain. 
 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 Stimwave PNS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Stimwave peripheral nerve stimulator (PNS) system (64590, L8680, 
L8683, and 64555).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a continued SNF stay. The Plan denied your request. The Plan says that your request for approval of continued 
admission in a SNF does not meet the requirements for approval. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that you recently had functional/clinical status 
change and required assessment by skilled nursing/therapy. Evaluating therapy notes show you are 
participating in skilled therapies. You require standby assist to maximal assist with self-care and mobility tasks. 
You have an unsteady gait with recommendations to stay in the current level of care. The documentation shows 
you continue to require daily skilled services on an inpatient basis in a skilled nursing facility. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time you no longer need the service and proper notice has been issued, or the 100-day 
Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine drug testing (80307, G0481) provided on June 28, 
2022. 
 
You asked the Plan to pay for urine drug testing. You say that this testing was medically necsesary. The Plan 
denied your request. The Plan says the enrollee's stated diagnoses codes are not listed in the codes the codes 
that support medical necessity for these tests. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested urine drug testing is covered for the 
diagnoses listed in the LCA. 
 
We looked at the file and Medicare rules. The enrollee does not one of the covered diagnoses for this testing. 
Based on this information, we decided that Medicare rules for coverage of urine drug testing have not been 
met. Therefore, we decided that the Plan does not have to pay for urine drug testing (80307, G0481) provided 
on June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance (E0486). 
 
You asked the Plan to pre-approve an oral appliance. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that an oral appliance is covered when the criteria (A-D) 
are met in the applicable LCD. 
 
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 appliance. Our reviewer says 
that the requested oral appliance is not medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has had an initial visit and polysomnography confirming obstructive sleep apnea with an 
AHI of 16. However, there is no documentation of a visit with a dentist who will fit the device and arrange for 
fabrication. 
 
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 appliance have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an oral appliance (E0486).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccine (90715) provided on December 8, 2022. 
 
You asked the Plan to pay for the tetanus vaccine. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted provides no additional information that justifies this 
request as there is no documentation or diagnosis of an injury noted. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine. 
The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any 
illness related to the tetanus vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus 
vaccine (90715) provided on December 8, 2022.  
 
Benefits for the tetanus vaccine 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the healthy food allowance. 
 
You asked the Plan to pre-approve the healthy food allowance. You say that you are on a fixed income and 
need assistance through the healthy food allowance. The Plan denied your request. The Plan says that your 
primary care physician (PCP) certified that you have Hypertension, which is not a qualifying condition for the 
healthy food allowance. 
 
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. The Plan did not provide a copy of the full 2023 Evidence of Coverage or 
medical records for this case. We asked for this documentation, but it was not provided to us. Without this 
information we cannot determine that the Plan's coverage rules support the denial in this case. Consequently, 
the Plan has not substantiated their denial in this case. Therefore, we decided that the Plan has to pre-approve 
the healthy food allowance.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair van transportation (A0130). 
 
You asked the Plan to pre-approve the transportation services. You say that you are completely bedridden or 
confined to a wheelchair and cannot voluntarily move your legs. You also say that your only choice for 
transport to the medical visits is a wheelchair van or an ambulance. The Plan denied your request. The Plan 
says wheelchair van transportation (A0130) is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair van transportation (A0130).
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 the enrollee requires physical, speech and 
occupational therapy to return to their prior level of functioning. The Plan denied your request. The Plan says 
an IRF admission is not medically necessary, and the enrollee's needs can be met in other settings. 
 
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 enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
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 Euflexxa. Our reviewer says that the 
enrollee does not meet the coverage criteria for Euflexxa. Our physician reviewer found there is no indication 
that the enrollee has tried and failed the required drugs. Our reviewer also found that there is no indication that 
the Plan's required drugs would likely be less effective and/or likely have adverse effects for 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
EPAP (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a 
back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for home health services provided on June 29, 2021. 
 
You asked the Plan to pay more for the home health services. You say that this claim was underpaid and did 
not require authorization. The Plan denied your request. The Plan says no medical records were sent in, so the 
claim was paid at the lowest billed Health Insurance Prospective Payment (HIPPS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the home health services have been 
met. Specifically, you have not provided any medical records to support the payment rate you are requesting.  
The Plan made multiple attempts and requests to get these records from you, but to date you have not 
responded. Therefore, we decided that the Plan does not have to pay more for home health services provided on 
June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx DiffDx-Melanoma testing (0314U) provided on 
October 3, 2022. 
 
You asked the Plan to pay for DecisionDx DiffDx-Melanoma testing. You say that this test was medically 
necessary and appropriate for this enrollee. The Plan denied your request. The Plan says this test is not 
approved for coverage by the Medicare MolDX program. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx DiffDx-Melanoma testing have not been met. Therefore, we 
decided that the Plan does not have to pay for DecisionDx DiffDx-Melanoma testing (0314U) provided on 
October 3, 2022.