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

 
We decided that the Plan does not have to pre-approve the elevating leg rests (E1012), electronic connection 
device (E2311), hand pads (K0108), arm rests (K0108), and the privacy flap (K0108). 
 
You asked the Plan to pre-approve the leg rest, connection device, hand pads, arm rests, and privacy flap. You 
say that the requested items are medically necessary. The Plan denied your request. The Plan says that the 
power leg rests, and electronic connection device are not medically necessary. The Plan also says that the hand 
pads, arm rests, and privacy flap are not covered. 
 
 The Plan must follow Medicare rules. Medicare rules say that elevating leg rests are covered if the criteria have 
been met. The rules say that an electronic connection device is medically necessary if it is necessary for the 
enrollee to control the power options through the joystick. The rules also say that for equipment to be covered, 
it must primarily serve a medical purpose.   
 
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 power leg rests and electronic 
connection device. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found 
that the enrollee has adequate strength to manage multiple switches and does not have extreme edema or 
flexion of the knees. 
 
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 power leg rests, and electronic connection device have not been met. The 
requested hand pads and privacy flap do not serve a purpose that is primarily medical in nature. The requested 
arm rests (K0108) are not separately payable as the arm rests are already included with the approved code 
E1007. Therefore, we decided that the Plan does not have to pre-approve the elevating leg rests (E1012), 
electronic connection device (E2311), hand pads (K0108), arm rests (K0108), and the privacy flap (K0108).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93005 and 94640 billed for date of service October 2, 
2022. 
 
You asked the Plan to pay for codes 93005 and 94640. You say that these services were provided emergently 
and should be covered. The Plan denied your request. The Plan says these services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. 

Records show that codes 93005 and 94640 has a status indicator of Q1, meaning that they are STV-packaged services. This means that they are billed on the same claim with a code that has a S, T, or V status indicator, there can be no separate payment made. In this case, codes 93005 and 94640 were billed on the same claim as code 99285. Code 99285 (and its associated outpatient hospital revenue code of 450), has a status indicator of V. This means that codes 93005 and 94640 cannot be separately paid.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 93005 and 94640 have not been met. Therefore, we decided that the Plan does not have to pay for codes 93005 and 94640 billed for date of service October 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF criteria, and you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the enrollee does 
not meet all the requirements for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted to the hospital on March 15, 2023, for metabolic encephalopathy with acute on chronic 
kidney injury and urinary tract infection. The enrollee required catheter placement and initiation of 
hemodialysis. The enrollees metabolic encephalopathy has resolved, and they continue to require dialysis. The 
enrollee does not require the intensity of rehabilitation physician oversight provided in an IRF setting. The 
enrollee does not require rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, 
tracheostomy management or neurogenic bowel and bladder management. The enrollees medical and 
rehabilitation needs do not require the intensive interdisciplinary approach provided at an IRF. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over 
seven consecutive days. As of April 4, 2023, physical therapy documentation indicated that the enrollee was 
walking 45 feet with a walker with contact guard assistance. Occupational therapy documentation dated April3, 
2023, indicated that the enrollee required supervision for bed mobility and transfers and minimal assistance for 
lower body dressing. The enrollee has had a decline from their baseline level of function and would likely 
benefit from therapy, but he does not require the intensity of therapies provided at an IRF. Therefore, the IRF 
admission is not 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), core buildup (D2950), root canal 
retreatment (D3347), an interim partial upper denture (D5820), and pontics (D6245) for tooth #4, #5, #6, #8, 
and #9. 
 
You asked the Plan to pre-approve the dental services. You say that you have an infection in your mouth and 
the dental procedures are necessary. The Plan denied your request. The Plan says your benefit for the crown 
and core buildup has already been exhausted. Also, the denial of authorization for the root canal retreatment, 
interim partial upper denture, and pontics is correct because they are not covered by the Plan. 
 
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, certain limitations apply. The record 
shows the Plan approved 2 crowns on April 2, 2023; therefore, your benefit for the crown and core buildup was 
exhausted on the date of approval of April 2, 2023. The root canal retreatment, interim partial upper denture, 
and pontics are not covered under the Plan's dental benefit. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740), core buildup (D2950), root canal retreatment (D3347), an interim partial 
upper denture (D5820), and pontics (D6245) for tooth #4, #5, #6, #8, and #9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested services. You say that you have not checked your sugars in 46 
days. The Plan denied your request. The Plan says you do not meet the criteria for coverage. 
 
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. There are no medical records provided to show that you use insulin 
with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results, or have had an in-person visit with their treating physician to assesses adherence to their 
CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for 
coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
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 enrollee deserves to be able to have a short stay 
at an IRF to regain their strength, independence and endurance to return home at an independent level as they 
were previously. The Plan denied your request. The Plan says based on the clinical information received, the 
enrollee does not meet the guidelines for IRF services. 
 
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, rehabilitation, and medical needs do not 
require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. 
While the enrollee may benefit from physical and occupational therapy, the enrollee's rehabilitation needs can 
be provided in a lower intensity and alternate setting such as a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have documented skilled therapy needs. The enrollee is noted to 
have a decline in function following several hospitalizations in the last six months. The enrollee is reported to 
have been previously independent. The enrollee appears willing to participate in therapy, and there is 
insufficient evidence to show that she has reached a plateau in function. Daily skilled services are required to 
establish a maintenance program and/or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 enrollee has been diagnosed with severe 
COPD. The medical 
records document his disease is worsening resulting in more shortness of breath. The portable ventilator 
provides positive pressure ventilatory support with nasal pillows. The Plan denied your request. The Plan says 
the request is not medically necessary because this device is not considered standard of care to treat the 
enrollee's condition. 
 
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 service is not medically necessary. Our physician reviewer found the enrollee has severe COPD. The 
Life2000 device is not a true ventilator, because it is not capable of providing full ventilatory support. Its 
primary intended use is during activity, and not to treat chronic CO2 retention during sleep. There is inadequate 
evidence of the safety and effectiveness of this device in the treatment of COPD. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
resin-based composite - one surface, anterior (D2330), limited oral evaluation - problem focused (D0140), and 
endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided on March 1, 2022, to March 
29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to go to a specialist and the provider 
was the only one in the area that you could go to do the work. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits. 
 
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. 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an intraoral - periapical first radiographic image (D0220), resin-based composite - one surface, 
anterior (D2330), limited oral evaluation - problem focused (D0140), and endodontic therapy, anterior tooth 
(excluding final restoration) (D3310) provided on March 1, 2022, to March 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic radiosurgery (SRS). 
 
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 that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found that while the enrollee has had progression 
of intracranial and extracranial metastases, she is a candidate for systemic therapy that has not yet been 
initiated but with the plans to do so in the near future. The requested SRS is the standard of care for the 
enrollee's condition and is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve stereotactic radiosurgery (SRS).  
 
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 a vagus nerve stimulator (VNS). 
 
You asked the Plan to pre-approve a vagus nerve stimulator. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that vagus nerve stimulators are only covered for 
enrollees with medically refractory partial onset seizures for whom surgery is not recommended or for whom 
surgery has failed or enrollees enrolled in a clinical study. 
 
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 vagus nerve stimulator. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found you suffered a stroke in 2017. The documentation shows that you are noted to 
have post-stroke spastic hemiparesis. The documentation does not support that the VNS placement is for/part 
of a clinical research study. Therefore, you do not meet criteria for the requested services. 
 
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 vagus nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vagus nerve stimulator (VNS).
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 you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the SNF services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist; 
however, skilled therapy is not required on a daily basis. The enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. The enrollee does not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care.