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

 
We decided that the Plan has to pay for the transcutaneous electrical nerve stimulation (TENS) unit (E0730) 
provided on September 28, 2022. 
 
You asked the Plan to pay for the TENS unit. You say that you want to appeal this denial. The Plan denied 
your request. The Plan says that the documentation submitted did not include a Proof of Delivery, or a Delivery 
Ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order, and proof of delivery. The record includes a valid proof of 
delivery as the tracking number matches the tracking number listed on the packing slip. Therefore, we decided 
that the Plan has to pay for the transcutaneous electrical nerve stimulation (TENS) unit (E0730) provided on 
September 28, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment (D8090). 
 
You asked the Plan to pre-approve comprehensive orthodontic treatment. You say that you want the Plan to 
cover the service. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive orthodontic treatment (D8090).
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 currently recovering from surgery, and you 
need to learn how to function in your home environment. You say you do not feel you can safely do so without 
rehabilitation training. The Plan denied your request. The Plan says your request for an IRF admission 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 not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve inpatient psychiatric hospitalization. You say that the request is medically 
necessary for further stabilization, diagnostic clarification, mediation management, unit milieu/therapy. The 
Plan denied your request. The Plan says the request is not medically necessary because the records received 
show the enrollee is not a threat to himself or others, appears to be at baseline for his chronic mental state and 
is able to care for himself. 
 
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 pre-approve inpatient psychiatric hospitalization. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found it was not 
expected this enrollee would improve in a reasonable period as he did not have dangerousness to self or others, 
auditory or visual hallucinations, delusions and was cooperative with evaluation. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care as he did not have dangerousness to self or others, perceptual disturbance including 
delusions, auditory or visual hallucinations. The health plans denial of inpatient psychiatric services appears 
appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to 
himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It 
did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose 
of diagnosis. Our reviewer is unable to find an individualized treatment plan however the entire record is not 
present. It did appear that the records were supervised and evaluated by a physician. Based upon review, the 
records provided for the admission of this enrollee does not meet criteria for acute inpatient mental health 
treatment as this enrollee was not shown to be a danger to himself or others, no auditory or visual 
hallucinations. He is noted to be cooperative and compliant with treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
March 10, 2023. 
 
You asked the Plan to pre-approve continued SNF care. 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 must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee has been weak and deconditioned and has been working 
with physical and occupational therapy. As of March 8, 2023, and March 9, 2023, the enrollee was walking 75 
to 100 feet with a rolling walker with contact guard assistance and was contact guard to stand-by assist for 
transfers and was moderate assist for some activities of daily living (bathing). 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 not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care after March 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to a medical appointment. The Plan denied your request. The Plan says your benefit only allows 48 one-way 
trips with each one-way trip not exceeding 50 miles of driving distance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 64.4 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
February 15, 2023. 
 
You asked the Plan to pre-approve SNF care after February 15, 2023. You say that the continued admission to 
a SNF is medically necessary. The Plan denied your request. The Plan says the continued 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 after February 15, 2023. 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 not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does 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 after February 15, 2023, have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after February 15, 
2023.
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 services are medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet functional or medical necessity criteria 
for inpatient rehab 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 enrollee does not have complex or intensive rehabilitation needs. The enrollee 
does not require frequent physiatry oversight. IRF criteria not 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 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: 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 will provide the 
enrollee with the services necessary. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require transfer to a long-term 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but is still somewhat unstable and should only 
require short-term additional acute care services that can safely be performed until more stable and appropriate 
for a lower level of care. The enrollee does not require services at the LTACH that are not already available at 
the current facility. Completion of treatment is recommended at the current 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a PressureSmart mattress and adjustable base 
provided on October 4, 2022. 
 
You asked the Plan to reimburse you for the mattress and adjustable base. You say that you were advised your 
plan covers a portable bed mattress. You say that you tried your roommates portable mattress for one week. 
You say that you benefited from using this type of mattress. You also say that you would have fewer medical 
visits if you had this bed. The Plan denied your request. The Plan says the items in this case do not have a 
primarily medical use. 
 
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 reimburse you for a PressureSmart mattress and adjustable base provided 
on October 4, 2022.
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 criteria 
for admission to the LTACH have not been met, the enrollee's medical needs are being met in the current acute 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH, the enrollee is receiving appropriate care at the present acute care hospital. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the enrollee has poor balance. The Plan denied 
your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
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 the enrollee can benefit from an acute rehab to 
optimize their level of functioning prior to returning home. You say that the enrollee requires daily physician 
oversight for their acute medical problems that have left them at a functional status below their baseline. The 
Plan denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs 
can be met at an alternate level of care. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit-to-stand frame/table system. 
 
You asked the Plan to pre-approve a combination sit-to-stand frame/table system. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested item 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 a combination sit-to-stand frame/table 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has advanced dementia and functional 
quadriplegia. The enrollee requires assistance of two to three to transfer to a wheelchair. There are no therapy records submitted. There are no records submitted indicating the sit to stand transfers device is safe and 
reasonable for the enrollee. A sit to stand device requires assistance and participation from the enrollee. 
Therefore, the enrollee does not meet criteria for the requested device. 
 
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 combination sit-to-stand frame/table system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a combination sit-to-stand frame/table system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70551 billed for date of service December 8, 
2022. 
 You asked the Plan to pay for procedure code 70551. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70551 is bundled into payment for code 
70553. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70551 
is a column II code to column I code 70553. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70551 billed for date of service December 8, 
2022.