Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone and cannot navigate up and down 
your stairs after your surgery. The Plan denied your request. The Plan says that the request 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that you have complex functional impairments since arthroplasty is bilateral and the orthopaedic surgeon 
documents that you are specifically high risk for contracture/soft tissue adhesions. Clinical documentation 
shows that you would be expected to require close medical monitoring by a physiatrist on an inpatient basis 
during rehabilitation. IRF criteria have been met.  
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of blepharoptosis. 
 
You asked the Plan to pre-approve the procedure. You say that the denial is incorrect. The Plan denied your 
request. The Plan says this 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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the the photos provided do not clearly demonstrate a MRD of 2.0mm or less bilaterally; a 
corneal light reflex is not visible, and the eyelids appear to be near the op margin of the iris. The external 
photos do not clearly demonstrate a MRD of 2.0mm, and do not correlate with the visual field findings. The 
visual fields in the right eye do not demonstrate a significant improvement with taping. Additionally, the 
progress notes indicate "no symptoms" and there are no complaints of the droopy eyelids affecting activities of 
daily living.  
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repair of blepharoptosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standard wheelchair rental (K0001). 
 
You asked the Plan to pay for the standard wheelchair rental. You say that the item should be covered. The 
Plan denied your request. The Plan says the capped rental period (13 months) for this item has been exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the standard wheelchair rental have not been met. Therefore, we decided that the Plan does not 
have to pay for the standard wheelchair rental (K0001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary function testing to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve pulmonary function testing. You say that the enrollee cannot find a 
contracted facility to perform this testing. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan and this testing can be performed by an in-network facility. 
 
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 
pulmonary function testing to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care. The 
Plan denied your request. The Plan says criteria 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 for transfer at 
this time and should only require short-term additional acute care services that can safely be administered at the 
current facility until more appropriate for a lower level of care (more stable feeding source). The enrollee does 
not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH 
is not medically necessary as the enrollee is not yet stable for transfer and as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that if you have proper rehabilitation in place, you will 
improve and be able to go home in a timely manner. The Plan denied your request. The Plan says you do not 
meet criteria for admission to an inpatient rehabilitation facility. 
 
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 your nursing medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
hip replacement surgery. Medical problems are stable. While you have a need for physical or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 4 power wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that the enrollee has hemiplegia. The 
Plan denied your request. The Plan says the request is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The requested wheelchair is not considered medically reasonable 
and necessary. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 4 power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0652) and 
accessories (E0656, E0667). 
 
You asked the Plan to pre-approve the PCD and accessories. The Plan denied your request. The Plan says the 
coverage criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD and related supplies are covered for the 
indications established 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 the PCD and accessories. Our reviewer 
says that the requested PCD and accessories are not medically reasonable and necessary. Our physician 
reviewer found that the provided records do not document that the enrollee has lymphedema extending onto the 
chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, nor that the chest, 
trunk and/or abdominal lymphedema has failed to improve with a four-week trial as required by the LCD. 
 
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 PCD and accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pneumatic compression device (PCD) (E0652) and accessories (E0656, E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on June 1, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that this should be a $0 copayment under 
your vision care benefit. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
 
 The record shows this claim was approved, and you are responsible for a cost-sharing amount. You have been 
asked to pay $374.90, which is 20% coinsurance of the allowed amount for an injection ($1,874.49 x 20% 
coinsurance = $374.90). This item/service falls within the Medicare Part B prescription drugs benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for an injection provided on June 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient facility services provided from January 10, 
2022, to February 21, 2022, out of the country. 
 
You asked the Plan to pay for the inpatient facility services. You say that the surgeries provided were 
necessary, and rendered on an emergency basis. The Plan denied your request. The Plan says these services 
were foreseen, and do not meet the criteria for emergent/urgently needed care. 
 
The Plan follows Medicare rules. Medicare rules say that items and services furnished outside the United States 
are excluded from coverage except for the services listed in the Medicare rules section of this letter. 
 
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 inpatient facility services. Our reviewer 
says that the inpatient facility services were not reasonable and necessary to have been provided in another 
country. Our physician reviewer found the services could have been foreseen prior to leaving the service area, 
as the vascular disease was being actively evaluated and managed. Our reviewer found that the emergent basis 
for the provided service is unclear, and it is unclear why you could not have returned home for management. 
Our physician reviewer also found in summary, there is insufficient documentation to support the authorization 
for emergent, out-of-area surgical revascularization in your 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 inpatient facility services have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient facility services provided from January 10, 2022, to February 21, 
2022, out of the country.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiovascular services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the requested 
services are available in network. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
cardiovascular services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the MyoPro is not known to be 
effective, based on scientific evidence, professional standards and expert opinion, in improving health 
outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this 
patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. The services are 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 MyoPro orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator (E0747). 
 
You asked the Plan to pre-approve the bone growth stimulator. You say that this device is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a non-spinal electrical osteogenesis stimulator 
(E0747) is covered for Non-union of a long bone fracture defined as radiographic evidence that fracture healing 
has ceased for three or more months prior to starting treatment with the osteogenesis stimulator. 
 
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 bone growth stimulator. Our 
reviewer says that this device is not medically necessary. Our physician reviewer found documentation is not 
clear regarding the fusion being in a non-union, as there were no serial radiographs provided for review. 
 
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 bone growth stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone growth stimulator (E0747).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82465, 83036, 83718, 83721, 84153, 
84439, 84443, 84478 and 86703) provided on May 2, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says these laboratory services were not medically 
necessary based on the diagnosis codes billed. 
 
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 pay for laboratory services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided are unclear as to how screening lab tests for cholesterol, prostate 
cancer, thyroid disorders, diabetes, and hCG (human chorionic gonadotropin) relate to the enrollee's 
hematological issue. These services cannot be found reasonable and necessary based on the information 
provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services (82465, 83036, 83718, 83721, 84153, 84439, 84443, 84478 and 86703) 
provided on May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back-up battery (A9270). 
 
You asked the Plan to pre-approve back-up battery. You say that you recently had surgery. You say that there 
is an electrical energy problem in your area. You say that you cannot afford to turn on a generator. You also 
say that this is necessary to use your continuous positive airway pressure (CPAP) machine. The Plan denied 
your request. The Plan says power generators or alternative power sources needed in the event of 
power outages are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a back-up battery (A9270).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 30, 2021, to December 10, 2021. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, per 
Medicare requirement for final home health prospective payment system (PPS) claims to be processed, a RAP 
claim must be submitted and processed to receive the balance of payment due for the completed period. 
Therefore, as a RAP claim for the 30-day period of care was not processed for payment, the Medicare rule for 
reimbursement of the final home health PPS claim for November 14, 2021, to December 10, 2021 has not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the 
enrollee from November 30, 2021, to December 10, 2021.