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. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that you were measured for a 
motorized wheelchair. You also say that you have not heard anything back. The Plan denied your request. The 
Plan says the notes do not show that the Group 3 standard power wheelchair is appropriate. 
 
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 Group 3 power wheelchair.
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 an expedited reconsideration for 
the denial of an IRF admission. You believe inpatient rehabilitation is both physically and medically necessary 
for the enrollee to return home at their maximum level of functioning with a decreased risk for readmission. 
The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria for IRF 
placement. 
 
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: 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. You say that you need these 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. 
Medicare rules also say that for Medicare to consider coverage and payment for any item or service, the 
information submitted by the supplier or provider must corroborate the documentation in the beneficiary's 
medical documentation and confirm that Medicare coverage criteria have been met. 
 
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, your provider has not returned the requested 
information to show that you 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on May 6, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. 
Therefore, we decided that the Plan does not have to pay for the PrismRA test provided on May 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart with quantitative calcium scoring 
(75571). 
 
You asked the Plan to pre-approve quantitative calcium scoring. You say that you are having chest pain and 
want a diagnosis quickly. The Plan denied your request. The Plan says that the screening procedure 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 quantitative calcium scoring. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that you are 
asymptomatic. The health plan must follow CMS rules and guidance. The clinical value of repeat calcium 
scoring in a short time frame for coronary artery disease reassessment has not been demonstrated in the peer-
reviewed literature. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of quantitative calcium scoring have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CT scan of the heart with quantitative calcium scoring (75571).
Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 6 of the requester 12 physical therapy sessions. We decided that 
the Plan does not have to pre-approve all 12 of the additional sessions.  
 
You asked the Plan to pre-approve 12 home health physical therapy sessions. You say that these additional 
sessions are medically necessary. The Plan says that these services are not medically necessary. 
 
We decided that the Plan has to pre-approve 6 additional physical therapy sessions.  
 
Our doctor found that the enrollee was noted to have a strain of her iliopsoas muscle, and this can be addressed 
with 6 visits of home health physical therapy as well as a transition to a home exercise program. Therefore, we 
decided that the Plan has to pre-approve 6 of the 12 additional physical therapy.  
 
We also decided that the Plan does not have to pre-approve 6 of the requested 12 sessions. 
 
Our doctor found that the enrollee does not need all 12 sessions. Therefore, we decided that the Plan does not 
have to pre-approve all of the requested physical therapy sessions. 
 
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. 
 
 
You asked the Plan to pre-approve a home ventilator. You say that the records provided support the need for 
the requested home ventilator. The Plan denied your request. The Plan says the requested device is non-covered 
because it would be used in a bi-level positive airway pressure (BiPAP) mode. 
 
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 criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. The enrollee has severe COPD and was recently hospitalized with an exacerbation.  
Intubation was required and the enrollee suffered a cardiac arrest.  Resuscitation was successful.  Arterial blood 
gas (ABG) was consistent with acute on chronic hypercarbic respiratory failure.  The enrollee may benefit from 
BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that the non-
programmable PCD would be an appropriate treatment option for the enrollee. The records have been enclosed 
to support the treatment for the enrollee's lymphedema. The Plan denied your request. The Plan says this 
pneumatic compression device is not medically necessary because there is no documentation of a failed four-
week trial with a PCD coded as E0650 or E0651 and there is no documentation of edema extending onto the 
abdomen, trunk, or chest. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
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. The Plan denied your request. The Plan says all 
services that would be provided in the LTACH are being provided in the current acute care setting which is 
already approved. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting currently being offered by the health plan. 
 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable for 
transfer. The Plan denied your request. The Plan says an LTACH should not take the place of treatment in an 
acute care hospital. 
 
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 physician 
reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. The health plan has approved ongoing care in the current acute 
care setting. The requested services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that this scan will aid in differential diagnosis and 
treatment planning. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the service 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement BiPAP device (E0470) and a humidifier 
(E0562). 
 
You asked the Plan to pre-approve a replacement BiPAP device and a humidifier. You say that the current 
machine is under recall, and it is not working. A new machine is needed. The Plan denied your request. The 
Plan says Medicare rules allow for a replacement device every 5 years if needed. It has not been 5 years since 
the plan purchased a BIPAP machine for you. The machine was not lost, stolen, or irreparable. 
 
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 BiPAP device on April 8, 2019. There was a voluntary manufacturers 
recall. The file also shows that a loaner BiPAP was provided to you until the replacement machine was 
delivered to you on March 6, 2023. The current BiPAP device serves the same purpose as a replacement 
BiPAP device and a humidifier. Therefore, we decided that the Plan does not have to pre-approve a 
replacement BiPAP device (E0470) and a humidifier (E0562).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95807). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that sleep study can 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 sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the provided records do not document 
necessity of the study given the adequate home sleep study confirming the diagnosis of obstructive sleep apnea. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95807).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spravato. 
 
You asked the Plan to pre-approve Spravato. You say that this is the next step for you. You say that you have 
exhausted all avenues with other depression medications. The Plan denied your request. The Plan says the 
requested drug 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 pre-approve Spravato. Our reviewer says that the 
requested drug, Spravato, is not medically necessary. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of  chronic depression, unspecified. The reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested drug is not medically reasonable 
or 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 Spravato have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Spravato.
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 
(OON) provider. 
 
You asked the Plan to pre-approve office visit. You say that the enrollee has upcoming surgery. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan and the enrollee can be treated 
within the Plan 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 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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that tests results prove medical necessity. The Plan 
denied your request. The Plan says necessary services may be obtained 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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic panel billed with codes 81206, 81292, 81295, 
81298, 81317, 81321, 81162, 81301, 81191, and 81401 provided on February 20, 2022. 
 
You asked the Plan to pay for the genetic panel. You say that this claim should be paid. The Plan denied your 
request. The Plan says the testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The 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. Based on 
this information, we decided that Medicare rules for coverage of the genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for the genetic panel billed with codes 81206, 81292, 
81295, 81298, 81317, 81321, 81162, 81301, 81191, and 81401 provided on February 20, 2022.