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 with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
requested power wheelchair is medically necessary for the enrollee. The Plan denied your request. The Plan 
says the enrollee does not have a medical need for multiple power options. The Plan also says that the upgraded 
electronics are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the enrollee has a Group 3 neurological 
diagnosis of familial spastic paraplegia. The enrollee has a mobility deficit that impairs mobility related 
activities of daily living (MRADLS) in the home.  The documentation states the enrollee has been using a 
manual wheelchair, but it is getting more difficulty to use this device and they have shoulder pain. The 
documentation states the enrollee is unable to use a walker or cane and is non ambulatory. The documentation 
indicates the enrollee receives Botox for spasticity. There is no documentation of anti-spasticity medications. 
The enrollee has been using a manual wheelchair without a cushion and has no pressure ulcers currently or a 
history of pressure ulcers. The documentation does not reveal that the enrollee is at high risk for development 
of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating 
system to manage increased tone or spasticity. The enrollee does not have a musculoskeletal condition or the 
presence of a cast or brace which prevents 90-degree flexion at the knee; significant edema of the lower 
extremities that requires an elevating legrest; or meets the criteria for and has a reclining back on the 
wheelchair. Therefore, the reviewer found that the requested Group 3 power wheelchair with multiple power 
options is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. As the base power wheelchair is not covered, the associated accessories are also denied. Based on this information, we decided that Medicare rules for 
coverage of a Group 3 power wheelchair with multiple power options have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options 
and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Supartz (J7321, 20610 and 77002). 
 
You asked the Plan to pay for the Supartz. You say that the service is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 the Supartz. Our reviewer says that this is 
not medically necessary. Our physician reviewer found This is an off-label use of the drug. 
 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 Supartz have not been met. Therefore, we decided that the Plan does not 
have to pay for the Supartz (J7321, 20610 and 77002).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV), group 1 standard, 
patient weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a POV. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the provider has not submitted clinical 
information to determine whether the scooter is repairable or the reason for a new scooter. 
 
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 you received a scooter in 2019. This scooter serves the same purpose as the requested POV. 
The records show that the provider did not submit clinical information to determine whether your current 
scooter is repairable, the reason for a new scooter or whether you continue to meet the Medicare criteria for a 
POV. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (POV), group 
1 standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
sensor and transmitter (A4239). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM sensor and transmitter. You say that you are diabetic 
and need the requested device to sustain life. The Plan denied your request. The Plan says you are not on 
insulin. You do not meet criteria for approval of the requested CGM and supplies. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 CGM sensor 
and transmitter have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G6 continuous glucose monitor (CGM) sensor and transmitter (A4239).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (11042) provided on October 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery..  
 
We looked at the file and Medicare rules. Payment for the requested services (11042) is included in the global 
surgery payment for the procedure (28810) provided on August 11, 2022, which has a 90-day global period. 
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 pay for the services (11042) provided on October 14, 
2022.
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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the request for IRF services does not meet the 
requirements for approval. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the services 
requested are not medically necessary. 
 
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. medical records have not been provided or attempted to be provided by the plan. 
Therefore, we decided that the Plan has to pre-approve home health 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for approval have not been met. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling and bitewing x-ray (D0272, D2392) provided on 
May 31, 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 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 January 1, 2022. 
Therefore, we decided that the Plan does not have to pay for a filling and bitewing x-ray (D0272, D2392) 
provided on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an out-of-network podiatry visit provided on July 6, 2022. 
 
You asked the Plan to pay for an out-of-network podiatry visit. You say that this was an in-network treatment 
that was also medically necessary. 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 $400 deductible which applies to out-of-network provider and 
professional services.  
 
The item or service you asked the Plan to pay for falls within the out-of-network provider and professional 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $400 deductible which applies to out-of-network provider and professional services.  Therefore, the $100 charge is upheld. This cost sharing is a contractual obligation that had not been met at the 
time an out-of-network podiatry visit was received on July 6, 2022. Therefore, we decided that the Plan does 
not have to pay for an out-of-network podiatry visit provided on July 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient psychiatric hospitalization provided on 
September 18, 2022, to October 3, 2022. 
 
You asked the Plan to pay for acute inpatient psychiatric hospitalization. You say that these services were 
medically necessary for the enrollee. The Plan denied your request. The Plan says these services could have 
been provided at a less restrictive setting. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient psychiatric hospitalization. 
Our reviewer says that this inpatient admission was not medically necessary. Our physician reviewer found 
these services could have been treated in a lesser restrictive setting as he was not showing any suicidal or 
homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or 
aggression being cooperative and compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pay for acute inpatient psychiatric hospitalization provided on September 
18, 2022, to October 3, 2022.
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 the LTACH services. You say that you are requesting reconsideration 
stating the enrollee clearly exceeds the criteria for a medically appropriate LTACH admission. The Plan denied 
your request. The Plan says criteria for admission to the LTACH 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care 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 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 admission to LTACH is medically 
necessary as the enrollee's care needs cannot be met in a lower level of care. The Plan denied your request. The 
Plan says the enrollee's medical needs are being 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 was admitted with urosepsis and aspiration pneumonitis. The record 
indicates that the enrollee has ongoing acute medical issues and still requires acute care services. The enrollee 
continues to receive acute care services, and these have not been denied. The medical record does not indicate 
that the enrollee requires services that they are not currently receiving but that would be available at the 
LTACH facility. The elements of the coverage rules are not satisfied. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra (J3590). 
 
You asked the Plan to pre-approve Actemra. You say that the requested drug is medically necessary for the 
enrollee's treatment. The Plan denied your request. The Plan says drugs supplied by a pharmacy are not covered 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Actemra (J3590).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the sales tax, and the progressive lenses provided 
on December 1, 2022. 
 
You asked the Plan to pay for the frames, the sales tax, and the progressive lenses. You say that you are 
covered for a free standard pair of glasses after cataract surgery. You say want to be reimbursed the cost of the 
glasses. The Plan denied your request. The Plan says the claim was reprocessed to reimburse you with the 
remaining $47.20 from the eyewear allowance. 
 
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 after each cataract surgery. 
 
We looked at the file and the Plan's rules. Specifically, the Plan reprocessed the claim and applied the 
remaining $47.20 of the $150 of the allowance towards the progressive lenses. The frames paid correctly, and 
the sales tax is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of 
the frames, the sales tax, and the progressive lenses have not been met. Therefore, we decided that the Plan 
does not have to pay for the frames, the sales tax, and the progressive lenses provided on December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 10, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. In this case, the test panel was billed with multiple codes and 
multiple units of service. The panel cannot be unbundled and must be billed with one unit of service. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab panel provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and a portable oxygen 
concentrator (E1392) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an oxygen concentrator and a portable oxygen concentrator. You say that 
the requested devices are medically necessary. The Plan denied your request. The Plan says you must use 
network providers to receive services. There are in-network providers available. 
 
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 items/services at issue in this appeal. 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 
an oxygen concentrator (E1390) and a portable oxygen concentrator (E1392) to be provided by an out-of-
network (OON) provider.