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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for an 
LTACH, and the services the enrollee's needs cannot be accomplished at a lower level of care. The Plan denied 
your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can safely 
receive the care they need in the current hospital 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 that the enrollee has ongoing medical needs and still requires acute care services 
before transitioning to a lower level of care.  The enrollee does not require services that they are not currently 
receiving but that would be available at the LTACH 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power wheelchair (K0813), a u-1 sealed lead 
acid battery (E2365x26) and a battery charger (E2366x13). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary for the enrollee. The Plan denied your request. The Plan says office 
notes dated 9/14/22 show that the enrollee has 5/5 strength throughout with good tone and has a symmetrical 
and balanced gait. The face-to-face examination indicates that the enrollee has the upper extremity strength to 
self-propel a manual wheelchair. The enrollee does not meet the criteria for this group 1 standard power 
wheelchair. Wheelchair accessories are not approvable without base wheelchair approval. 
 
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 the enrollee does not have a mobility deficit that impairs his participation in MRADLs, his 
condition can be improved by a walker, cane or manual wheelchair or the enrollee cannot safely operate the 
PMD being requested. 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 wheelchair (K0813), a u-1 sealed lead 
acid battery (E2365x26) and a battery charger (E2366x13).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
19, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 sensor. 
 
You asked the Plan to pre-approve Dexcom G6 sensor. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
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. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, 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 Dexcom G6 sensor have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Dexcom G6 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a varicose vein treatment procedure (36475, 36471). 
 
You asked the Plan to pre-approve the varicose vein treatment procedure. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that indications for surgical treatment of varicose veins 
include documentation that the enrollee has an absence of significant peripheral arterial diseases. 
 
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 varicose vein treatment procedure. 
Our reviewer says that the procedure is not medically necessary. Our physician reviewer found there is 
documentation that there are potential plans for additional revascularization efforts. The patient has peripheral 
arterial disease. At this point it would not be appropriate to ablate any further saphenous veins as they might 
serve as a conduit for revascularization. 
 
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 varicose vein treatment procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a varicose vein treatment procedure (36475, 36471).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on June 01, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Ambulance Services. 
 
You have been asked to pay a $250 copayment for ambulance transport. This item/service 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 transport 
provided on June 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee has a continuously rising prostate 
specific antigen (PSA). The Plan denied your request. The Plan says there are in-network specialists who take care of the problems 
the enrollee is having. 
 
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 file shows that 12 OON visits were requested. The Plan has agreed to pre-approve 1 OON visit. 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 additional OON services. Therefore, we decided that the Plan does not have to pre-approve 
additional urology services to be provided by an out-of-network (OON) provider at this time.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in whirlpool tub. 
 
You asked the Plan to pre-approve a walk-in whirlpool tub. You say that you disagree with the denial of the 
requested whirlpool tub. The Plan denied your request. The Plan says neither Medicare nor the enrollee's health 
plan cover this item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in whirlpool tub.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 27, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you are not able to get to the toilet alone. 
The Plan denied your request. The Plan says the item is not being used to take care of a medical need. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a raised toilet seat.
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 you are requesting an expedited decision 
for the enrollee that meets full LTACH criteria. By waiting for a standard services decision may seriously 
jeopardize the enrollee's life, health, or the ability to regain maximum function. At issue as a LTACH 
submission medical records were submitted to review. The Plan denied your request. The Plan says LTACH 
services being requested do not meet the requirements for approval. The records do not show the enrollee needs 
continued treatments and care that can only be given in a hospital setting, the continued care needs include, IV 
antibiotics, wound care, tube feedings and physical therapy. When ready to leave the hospital, the enrollee may 
safely receive this care in another setting, such as a skilled nursing facility (SNF) or at home with home health 
services. 
 
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. 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. 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 a Dexcom G6 therapeutic continuous glucose monitor 
(CGM) and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM and supplies. You say that you feel the requested 
CGM, and supplies should be covered because you are having difficulty checking your BG's manually and your 
fingers are worn out due to the continuous testing over the years. The Plan denied your request. The Plan says 
you take fixed dose insulin twice a day and you do not adjust an insulin dose based on your blood glucose 
results. You do not meet coverage criteria for the requested CGM. 
 
 
 
 
 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. The documentation indicates that you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
therapeutic continuous glucose monitor (CGM) and supplies (K0553, K0554).
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 updated notes and documentation 
received about the enrollee's condition support long term acute care hospital placement. The Plan denied your 
request. The Plan says the enrollee can stay at the hospital where they are until they could safely be transferred. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the medical record does not indicate that the enrollee requires services that they 
are not currently receiving but would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied, and the requested service cannot be recommended. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 item is medically necessary. The Plan 
denied your request. The Plan says this item is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in the policy will be denied as not reasonable and 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 a home ventilator. Our reviewer says 
that this item is not medically necessary. Our physician reviewer found the enrollee could be treated with a 
BiPAP machine with AVAPS capability.  
 
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. Specifically, home ventilators (E0466) 
when used as a BiPAP are not medically necessary. Therefore, we decided that the Plan does not have to pre-
approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this item is not covered by Medicare or 
the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on 
this information, we decided that Medicare rules for coverage of a power seat elevation feature have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vesicare. 
 
You asked the Plan to pre-approve Vesicare. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vesicare.  
 
Benefits for Vesicare may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve air ambulance transportation. 
 
You asked the Plan to pre-approve air ambulance transportation. You say that this transportation is necessary. 
The Plan denied your request. The Plan says air ambulance transportation is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transportation. Our 
reviewer says that you do not meet criteria for air ambulance transportation. Our physician reviewer found the 
documentation does not support that your condition is such that the time needed to transport you by ground, or 
the instability of ground transportation, poses a threat to your survival or seriously endangers your health. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air ambulance transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve air ambulance transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nepro nutritional drink (B4154). 
 
You asked the Plan to pre-approve Nepro nutritional drink. You say that you disagree with the denial. The Plan 
denied your request. The Plan says oral supplements are not covered by Medicare or the plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Nepro nutritional drink (B4154).