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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe chronic 
obstructive pulmonary disease (COPD) and was recently hospitalized for an exacerbation. The arterial blood 
gas (ABG) study was consistent with acute-on-chronic hypercarbic respiratory failure. He improved on bi-level 
positive airway pressure (BiPAP). The ventilator is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the left shoulder. 
 
You asked the Plan to pre-approve an MRI of the left shoulder. You say that the enrollee satisfies the 
requirements for approval of the MRI. The Plan denied your request. The Plan says that the enrollee does not 
meet the criteria for use of an MRI of the shoulder. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI of the left shoulder. Our 
reviewer says that an MRI of the left shoulder is reasonable and necessary for the enrollee. Our physician 
reviewer found the enrollee has had two full 6-week courses of physical therapy in the past, including the most 
recent in 2021. The enrollee takes over the counter non-steroidal anti-inflammatory drugs and does a home 
exercise program. Our reviewer found that the enrollee's physical exam shows some weakness with abduction. 
Our physician reviewer also found that based upon the enrollee's history of two courses of physical therapy and 
continued weakness with abduction, an MRI of the left shoulder is reasonable. 
 
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 MRI of the left shoulder have been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the left shoulder.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on June 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not request the panoramic x-ray and 
you do not feel that you should be responsible. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 13, 2020. You 
received a different full mouth x-ray on this date of service that applies to the same benefit as the panoramic x-
ray.  
 
 
 You would not be eligible for a full mouth or panoramic x-ray until August 13, 2023. Therefore, we decided 
that the Plan does not have to pay for a panoramic x-ray (D0330) provided on June 29, 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 LTACH care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 appears to be improving but still somewhat unstable and should only 
require short-term additional acute-care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current 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 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 the remaining 10 months requested for an external 
infusion pump and supplies. 
 
You asked the Plan to pre-approve the remaining 10 months requested for an external infusion pump and 
supplies. You say that the remaining 10 months requested for an external infusion pump and supplies are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
remaining 10 months requested for an external infusion pump (E0784) and supplies (A4225 and A4224). 
 
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 remaining 10 months requested for 
an external infusion pump and supplies. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet the c-
peptide requirement for insulin pump use.  It seems unreasonable to this reviewer to deny her the pump now if 
she has been using it for 3 months, but she does not technically meet the c-peptide requirement required for 
pump use. 
 
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 remaining 10 months requested for an external infusion pump and supplies 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the remaining 10 months 
requested for an external infusion pump and supplies.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation shows that you have functional impairments, however there are no 
complex functional deficits specified. You would not be expected to require intense therapy or interdisciplinary 
team management of rehabilitation in an IRF setting. Clinical documentation states that medical issues are 
stable and would not be expected to require continued inpatient hospitalization during rehabilitation. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says the requested item is not covered. However, the Plan also notes that the 
enrollee may be eligible for additional coverage with state Medicaid 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 pre-approve an 
occlusal guard (D9944).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that, based on the available medical records, the enrollee may benefit from BiPAP with average volume-
assured pressure support (AVAPs) during sleep as an outpatient; however, Medicare does not cover a home 
ventilator when used as BiPAP. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation shows that you have functional impairments but there are 
specified complex functional deficits thus you would not be expected to require intense therapy or 
interdisciplinary team management of rehabilitation in an IRF setting (primary team also documents skilled 
nursing facility as discharge plan). Clinical documentation states that chronic obstructive pulmonary disease is 
stable on room air thus no active medical comorbidities and you would not be expected to require continued 
inpatient hospitalization during rehabilitation. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second oxygen concentrator. 
 
You asked the Plan to pre-approve a second oxygen concentrator. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says a second oxygen concentrator for the 
second floor of the enrollee's home would be duplicative in nature and not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has an oxygen concentrator. This oxygen concentrator serves the same purpose 
as the requested second oxygen concentrator for use on the second floor of the enrollee's home. Therefore, we 
decided that the Plan does not have to pre-approve a second oxygen concentrator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radionuclide stress test and echocardiogram. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary due to a history of 
coronary artery disease and risk factors. The Plan denied your request. The Plan says the enrollee has no new 
cardiac symptoms and is medically stable from a cardiac standpoint. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of carrying out a radionuclide stress test and 
echocardiogram. The patient has a history of bilateral leg numbness. Previous cardiac catheterization shows 
only mild coronary artery disease. He has no cardiac symptoms. There is no evidence provided that would 
support the need for radionuclide stress testing or echocardiography. In summary, there is insufficient 
documentation to support the medical necessity for the requested cardiac stress testing or echocardiogram in 
this patients 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a radionuclide stress test and echocardiogram.
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 the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary, and the enrollee's needs can be met in an alternate level of care. 
 
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 the enrollee does not have documented skilled nursing or skilled therapy needs. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of their 
condition. The enrollees care needs can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not had a recent 
surgical procedure on the knees. The documentation does not reveal objective evidence of joint laxity or knee 
instability. The enrollee is ambulatory but the criteria for coverage are not met. The knee orthosis is therefore 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Besremi. 
 
You asked the Plan to pre-approve Besremi. 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. 
 
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 Besremi. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation provided 
indicating that the the Plans 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 Besremi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Besremi.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of a leadless pacemaker. 
 
You asked the Plan to pre-approve replacement of a leadless pacemaker. You say that the services are 
necessary. The Plan denied your request. The Plan says the enrollee is not part of an FDA approved study. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS covers leadless pacemakers when 
procedures are performed in Food and Drug Administration (FDA) approved studies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of replacement of a leadless pacemaker have not been met. Therefore, we decided that the Plan does 
not have to pre-approve replacement of a leadless pacemaker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-lower extremity prostheses, flex-walk system or 
equal (L5981). 
 
 
 You asked the Plan to pre-approve a flex-walk system. You say that a lower limb prosthesis with the 
components recommended above will allow the enrollee to reach her stated goals of returning to work, walk for 
exercise, and play with her daughter in the park which will require traversing uneven terrain such as grassy 
slopes and gravel. The Plan denied your request. The Plan says the request for an advanced foot cannot be 
approved at this time by Medicare or your health plan. A prosthetic leg with a foot that is used for a lower 
activity level may meet the enrollee's needs. As her ability to walk improves, higher activity level additions 
may meet her needs. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a flex-walk system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has had to use an ankle brace for stability and has become limited in her 
functional ambulation as a result of gait instability for long distances. The flex-walk system exceeds the 
enrollee's medical needs and is not medically necessary. The documentation does not support that the enrollee 
is a K3 ambulator. 
 
 
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 flex-walk system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an all-lower extremity prostheses, flex-walk system or equal (L5981).