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

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve the requested device. You say that you are unable to walk without being in 
extreme pain. The Plan denied your request. The Plan says this item is not covered. 
 
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 crutch substitute is not medically 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 knee scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the apicoectomy (D3410), bone graft in conjunction with 
periradicular surgery (D3428), and retrograde filling (D3430) provided on December 8, 2021. 
 
You asked the Plan to pay for the apicoectomy, bone graft, and retrograde filling. You say that this was 
necessary oral surgery and the best way to treat the issue and infection. You also say that you should only be 
responsible for a $395.00 copay. The Plan denied your request. The Plan says these services are not covered 
benefits under your dental plan. 
 
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 pay for the 
apicoectomy (D3410), bone graft in conjunction with periradicular surgery (D3428), and retrograde filling 
(D3430) provided on December 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
1, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were told by the billing 
department this bill would not be paid because the provider was not a provider with the insurance company. 
You also say that you were never informed at any time that the ambulance service was not an in-network 
provider. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
The Plan also says that this claim was processed at the in-network rate. 
 
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 a $180 
copayment for ground ambulance transportation.  
 The record shows the claim was processed correctly at the in-network rate. You have been asked to pay a $180 
copayment for ambulance services. Ambulance services falls within the Ambulance Services 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 copayment for ambulance services provided on November 1, 2021.  
 
Your complaint about the information received from the billing department is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 power operated vehicle. You say that this is medically reasonable 
and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a manual wheelchair. This means that Medicare rules 
for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 1 power operated vehicle (K0800).
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 requested services are necessary for you to be 
able to perform daily activities. 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 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 provided documentation indicates that your medical problems are stable. You do not have complex nursing or rehabilitation needs. The reviewer found that you do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. Therefore, the reviewer found that the requested IRF admission 
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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the request for a home mechanical ventilator set in IVAPS-AE (similar to AVAPS) 
mode that could be delivered by an E0471 bilevel positive airway pressure (BiPAP) with assist device, is not 
covered. 
 
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 the DME. Our physician reviewer 
found a home ventilator is not medically necessary. You have severe chronic obstructive pulmonary disease 
(COPD), but there is no documentation of carbon dioxide (CO2) retention on an arterial blood gas (ABG) done 
while stable as an outpatient. There is no documentation of failure of BiPAP, and it appears BiPAP with 
average volume-assured pressure support (AVAPS) has not been tried. Medicare does not cover a home 
ventilator when used as BiPAP.  You have a Trilogy ventilator, but usage data shows she is using it for at least four (4) hours, per day, for less 
than 50% of days, which does not meet minimum Medicare criteria of at least 70% of days. The denial is 
upheld. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the home ventilator (CPT code E0466).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for respiratory failure and orthostatic hypotension. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right genicular nerve block. 
 
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 enrollee has right knee pain due to 
osteoarthritis. The requested genicular nerve block is considered experimental/investigational in nature. Its use 
in the treatment of osteoarthritis is still uncertain and the subject of ongoing clinical trials. 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 right genicular nerve block.
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 inpatient level of therapy and additional medical 
management for co morbid conditions is required. You say that the enrollee meets the full IRF criteria 
according to CMS guidelines and a lower level of care cannot provide an interdisciplinary therapy approach. 
The Plan denied your request. The Plan says the enrollee's therapy needs can be provided at a lower 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 there is no documentation that the enrollee requires the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level is more 
appropriate in this case. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 reviewer found that the enrollee is receiving appropriate care at the present acute care hospital. 
The reviewer found that the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the 
reviewer found that the requested LTACH 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an elliptical trainer. 
 
You asked the Plan to pre-approve an elliptical trainer. You say that this equipment should not be listed as 
exercise equipment. The Plan denied your request. The Plan says neither Medicare nor the Plan covers this 
equipment. 
 
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 an elliptical trainer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI, spinal canal and contents, cervical; without 
contrast material (CPT code 72141). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our physician reviewer found 
the notes for February, 21, 2022, describe no red flag to mandate immediate MRI without a six (6) week trial of 
conservative management including monitored physical therapy (PT). No detailed neuro exam is in the records 
but there is no mention of radicular symptoms, absent or diminished reflex or weakness. The documentation 
does not show medical necessity; therefore, the exam cannot be called 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve 
MRI, spinal canal and contents, cervical; without contrast material (CPT code 72141).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and accessories for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says as the requested Group 3 power wheelchair with the described power options/features is 
not reasonable and necessary, none of the requested accessories can be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
by the physician assistant notes that the enrollee is using a rollator and uses a wheelchair when she comes to 
the office but not at home therefore it is not clear why she is unable to use a manual wheelchair. Furthermore, 
the physician assistant note does not reveal a detailed neuromuscular or musculoskeletal or upper extremity 
exam that indicates she cannot use a manual wheelchair. The documentation does not reveal that the enrollee 
uses a ventilator attached to a wheelchair, is at high risk for development of a pressure ulcer (Braden score was 
mild risk). She does not use intermittent catheterization. The physician assistant documentation does not 
indicate objective evidence of spasticity on a bilateral lower extremity physical exam that needs a power 
seating system for management. The documentation notes that the enrollee can stand pivot transfer. The 
documentation does not adequately support the need for a power tilt. The power seat elevator does not serve a 
primary medical need and cannot be considered medically necessary by Medicare criteria. The requested Group 
3 wheelchair with accessories exceed the enrollee's medical need. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with multiple power options and accessories for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vibone fusion enhancer. 
 
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 enrollee has back pain. The 
requested Vibone cellular therapy is considered experimental in spinal fusion surgery, as more research is 
needed to support its use. 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 Vibone fusion enhancer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from March 
31, 2022, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 mental health care. Our 
physician reviewer found in terms of Risk of Harm, the records support a score of 1 due to no current suicidal 
ideation or homicidal ideation. With regards to Functional Status, the records support a score of 1 due to some 
mild comorbidity. In terms of Medical, Addictive and Psychiatric Comorbidity, the records support a score of 1 
due to overall no comorbidity. In terms of level of stress of the Recovery Environment, the records support a 
score of 1 due to a low stressful environment. With regards to Level of Support for the recovery environment, 
the records support a score of 1 due to highly supportive environment and availability of treatment resources 
but also some difficulty in relationships with their family members. With regards to Treatment and Recovery 
History, the records support a score of 1 due significant response to treatment. In terms of Engagement and 
Recovery Status, the records support a score of 1 due to optimal to positive engagement for recovery. Thus, 
you have a composite score of 7. This correlates with treatment in a community-based outpatient treatment. All 
told, the requested residential treatment program services are not medically necessary for the treatment of you. 
Your composite score to the above criteria was much lower showing you could be treated in a lesser level of 
care including an outpatient 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 inpatient mental health care have not been 
met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health 
care from March 31, 2022, forward.