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

 
We decided that the Plan does not have to pay for a power wheelchair (K0825) and accessories (E2361, E2313, 
E2376, E0990, E0973, E0978, E1028, E0631, E0955). 
 
You asked the Plan to pay for a power wheelchair and accessories. You say that this is medically necessary. 
The Plan denied your request. The Plan says the submitted records do not show that the requirements for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a power mobility device is covered if the 
beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual 
wheelchair in the home to perform mobility-related activities of daily living (MRADLs) during a typical day. 
Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence 
of one or both upper extremities are relevant to the assessment of upper extremity function. 
 
We looked at the file and Medicare rules. The submitted medical records do not show that you do not have 
sufficient upper extremity function to self-propel an optimally-configured manual wheelchair. There is no 
documentation of limitations of strength, endurance, range of motion, or coordination, presence of pain, or 
deformity or absence of one or both upper extremities. 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 pay for a power wheelchair (K0825) and accessories (E2361, E2313, E2376, E0990, 
E0973, E0978, E1028, E0631, E0955).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 You asked the Plan to pre-approve an office visit. You say that you have been seeing this doctor for 15 years 
and he knows your history and performed your open-heart surgery. The Plan denied your request. The Plan 
says there are credentialed, experienced physicians within your network who could be utilized for your clinical 
condition. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 office visit. Our physician reviewer 
found that there is insufficient documentation to support the medical necessity for referral to an out-of-network 
provider for the office visit. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an office visit to be provided by an out-of-network provider.
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. The Plan denied your request. The Plan says the enrollee does not 
need an intensive team to follow the enrollee daily. 
 
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 physician reviewer found 
that you were admitted to the acute hospital with respiratory failure, congestive heart failure exacerbation, and 
pneumonia. You are medically stable and do not need rehabilitation physician's supervision 3 times per week 
for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no 
acute rehab nursing needs identified or documented. Therefore, an IRF admission is not medically necessary 
based on lack of medical complexity and acute rehab nursing needs. 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. While the enrollee receives daily wound care, her chronic wounds are 
unlikely to resolve despite such measures. The enrollee does not have documented skilled therapy needs. She 
appears to have reached a plateau in function. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of her condition. The enrollees care needs, custodial and intermittent, can, 
as a practical matter, 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you need transportation to 
appointments. The Plan denied your request. The Plan says you have exhausted the allowed benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 20 one-way trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional taxi transportation (A0100).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LINQ device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is needed to assist in managing treatment 
options. The Plan denied your request. The Plan says no reason was given as to why periodic non-invasive 
monitoring could not be used instead. 
 
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 device. 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 whether the requested authorization for placement of an implanted loop recorder (ILR) is 
medically necessary. While the patient has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a LINQ device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the cervical spine 
without contrast material (72125). 
 
You asked the Plan to pre-approve CT of the cervical spine. You say that this imaging service is medically 
necessary. The Plan denied your request. The Plan says the requested CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT of the cervical spine. Our reviewer 
says that the criteria for a CT scan are not met in this case. Our physician reviewer found that current 
guidelines do not readily recommend performance of advanced imaging in cases in which a patient presents 
with an uncomplicated primary headache disorder. In this case, you were noted to have headaches and a normal 
neurological examination. You had no findings on exam that were potentially suggestive of a process involving 
the cervical spine that would have necessitated performance of an imaging study. Rather, such testing would 
otherwise have been considered to exceed your clinical needs. Nor was it reasonable and necessary as part of 
the evaluation of your condition. As such services would not have been 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 CT of the cervical spine have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the cervical spine without contrast material 
(72125).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers 24 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a BestLift Car Transfer Lift (E1399). 
 
You asked the Plan to pre-approve a BestLift Car Transfer Lift. You say that the Hoyer lift that was provided 
under Medicare does not fit in your house and it cannot be utilized to lift you into the car for medical 
visits/appointments. The Plan denied your request. The Plan says the requested item is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a BestLift Car Transfer Lift (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings you purchased on September 13, 
2021, from an out-of-network (OON) durable medical equipment (DME) provider. 
 
You asked the Plan to pay for the OON compression stockings. You say that if you didn't purchase these 
stockings, you would not have been able to get the surgery you needed.  You said that you purchased these 
stockings at the pharmacy where you get your prescription medications. The Plan denied your request. The 
Plan says out-of-network durable medical equipment is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that for compression stockings, you pay 10% coinsurance upon written prescription from a network 
provider to a network DME or orthotics and Prosthetics supplier in your Primary Care Provider's referral 
circle.. 
 
The DME provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for the compression stockings you purchased on September 13, 2021, from an out-of-
network (OON) durable medical equipment (DME) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Kerecis Omega 3 (Q4158), Corplex P 
(Q4231), and Corplex (Q4232) to treat various skin cancers of the head and neck. 
 
You asked the Plan to pre-approve the use of Kerecis Omega 3, Corplex P, and Corplex to treat various skin 
cancers of the head and neck. You say that the use of Kerecis Omega 3, Corplex P, and Corplex to treat various 
skin cancers of the head and neck is medically necessary. The Plan denied your request. The Plan says the use 
of Kerecis Omega 3, Corplex P, and Corplex to treat various skin cancers of the head and neck is 
investigational. 
 
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 use of Kerecis Omega 3, Corplex P, 
and Corplex to treat various skin cancers of the head and neck. Our reviewer says that the use of Kerecis 
Omega 3, Corplex P, and Corplex to treat various skin cancers of the head and neck is not considered medically 
reasonable and necessary in this case. Our physician reviewer found based on the medical records provided 
there is no documentation that the requested wound treatments at issue in this case meet Medicare criteria for medically reasonable and necessary. The provided records do not document trial and failure of any other 
standard wound therapy interventions or any indication as to why the requested treatments are the most 
appropriate treatment option 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 the use of Kerecis Omega 3, Corplex P, and Corplex to treat various skin 
cancers of the head and neck have not been met. Therefore, we decided that the Plan does not have to pre-
approve the use of Kerecis Omega 3 (Q4158), Corplex P (Q4231), and Corplex (Q4232) to treat various skin 
cancers of the head and neck.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve cataract surgery. You say that you have had issues with the cataract surgery 
you received from your POD. The Plan denied your request. The Plan says your eye care must be provided by 
the assigned POD in the county where you reside. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The EOC confirms that you are 
assigned a POD and that POD is responsible for your treatment related to your eyes. The EOC also confirms 
that if you wish to change your POD, you must call member services. We found no exception that would 
require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-
approve cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve office visits to be provided by the requested out-of-network provider. You 
say that is a survivorship clinic, which covers aspects of care such as pain fatigue, fear of recurrence, living 
with uncertainty, neuropathy, lymph edema, bone loss, sexual dysfunction, cardiovascular disease, memory 
issues, and future cancer risk in a coordinated manner. You say that this type of comprehensive care planning is 
not covered by the Plan's Oncology Department or any other clinic within the geographic area accessible to the 
enrollee. The Plan denied your request. The Plan says there is no documentation that the patients care cannot 
be provided by the Plan's oncology, to help manage post cancer treatment side-effects, and the Plan behavioral 
health for mental health support. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office 
visits to be provided by the requested out-of-network provider.
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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested 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 a ventilator. Our reviewer says that the 
documentation does not support that Our physician reviewer found you have diagnoses of chronic obstructive 
pulmonary disease (COPD), chronic respiratory failure, and diabetes. The requested home ventilator when used 
to provide continuous positive airway pressure (CPAP) or bi-level PAP (with or without backup rate) therapy, 
regardless of the underlying medical condition, is not covered. Claims for ventilators used to provide CPAP or 
bi-level CPAP therapy will be denied as not reasonable and necessary.  Therefore, you do not meet criteria for the requested item. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010), prefabricated abutment 
(D6056), abutment supported porcelain/ceramic crown (D6058), and porcelain fused crown (D6240), provided 
by a participating provider. 
 
You asked the Plan to pre-approve implant placement, prefabricated abutment, abutment supported 
porcelain/ceramic crown, and porcelain fused crown. You say that you really need this dental work because 
you need help with your mouth health. The Plan denied your request. The Plan says the requested dental work 
is not covered. 
 
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, 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 
implant placement (D6010), prefabricated abutment (D6056), abutment supported porcelain/ceramic crown 
(D6058), and porcelain fused crown (D6240), provided by a participating provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve laser treatment for vitiligo. 
 
You asked the Plan to pre-approve laser treatment for vitiligo. You say that laser treatment for vitiligo is 
medically necessary. The Plan denied your request. The Plan says that laser treatment for vitiligo does not meet 
the Plan's Medical Policy coverage criteria. 
 
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 laser treatment for vitiligo. Our 
reviewer says that laser treatment for vitiligo is considered medically reasonable and necessary in this case. Our 
physician reviewer found that you have disseminated vitiligo, which is an appropriate disease for coverage for 
laser treatment of inflammatory skin diseases. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laser treatment for vitiligo have been met. Therefore, we decided that the Plan 
has to pre-approve laser treatment for vitiligo.  
 
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.