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

 
We decided that the Plan does not have to pre-approve a partial hospitalization. 
 
You asked the Plan to pre-approve a partial hospitalization. You say that you feel upset, angry, frustrated, 
anxious, insomnia, feelings of helplessness, and you are afraid of physically attacking others. You also say that 
you can explode at any moment, since when you have courage, you lose control of your impulses. The Plan 
denied your request. The Plan says the documented clinical findings do not justify the level of care requested. 
The Plan also says you can be managed safely at the outpatient level with an increase in the frequency of your 
visits with your psychiatrist for review/optimization of pharmacotherapy and treatment. 
 
The Plan follows Medicare rules. Medicare rules say that partial hospitalization is a distinct and organized 
intensive treatment program for patients who would otherwise require inpatient psychiatric care. 
 
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 partial hospitalization. Our reviewer 
says that you do not appear to require partial hospitalization treatment. Our physician reviewer found you are 
not showing any dangerousness to yourself or others and have not been exhibiting severe psychological or 
psychiatric impairment requiring this level of care. It does not appear medically necessary and reasonable to 
have psychiatric care provided at the partial hospitalization level of care rather than a lower 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 a partial hospitalization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a partial hospitalization.
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 LTACH services requested are 
medically necessary and will assist in the improvement of the enrollee's condition. The Plan denied your 
request. The Plan says the member is receiving appropriate in-patient acute care and is currently unstable for 
transfer to an LTACH. 
 
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 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. The health 
plan has approved ongoing care in the current acute care 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 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 the home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the enrollee should qualify for the equipment. 
Please review and reconsider. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in average volume assured pressure support (AVAPS) mode with Auto-EPAP (AE) that could be 
delivered by bilevel positive airway pressure (BiPAP) 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 chronic obstructive pulmonary disease (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 ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records document a diagnosis of chronic respiratory failure consequent to chronic 
obstructive pulmonary disease. The provided records document that the home ventilator is being requested for 
use in AVAPS mode with auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a 
back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide 
continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this policy 
will be denied as not reasonable and 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
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 reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found that the enrollee's 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's goal with a LTACH 
admission is to wean from ventilator and return home. The Plan denied your request. The Plan says the transfer 
to a long-term acute facility is not appropriate currently. 
 
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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for the office visit and x-ray provided on October 5, 2022. 
 
You asked the Plan to reimburse you for the practitioner services. You say that you received a letter saying that 
you were responsible for this bill. You say that you already paid $111.15 which you should not have done. You 
also say that this was supposed to be sent to Medicaid. The Plan denied your request. The Plan says that this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment for out-of-network Physician/Practitioner 
Services.  
 
The Plan says you must pay a coinsurance for the practitioner services. Based on the Plan contract, however, 
you cannot be asked to pay more than $0 copayment for out-of-network the practitioner services. Therefore, we 
decided that the Plan has to reimburse you for the office visit and x-ray provided on October 5, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs for a power wheelchair (K0108, K0739). 
 
You asked the Plan to pre-approve repairs for a power wheelchair. You say that you need repairs of your 
wheelchair after someone in the nursing home stole your chair and returned it with damages. The Plan denied 
your request. The Plan says the Medicare DME benefit does not cover DME in a SNF therefore a power 
wheelchair is never covered at your present location. Repairs for this item cannot be covered per Medicare 
policy. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that repairs for a power wheelchair is being requested for use in a SNF or hospital. Medicare 
rules show that for equipment to be covered, it must be appropriate and needed for use inside the home. 
Medicare does not consider a SNF or a hospital to be a home. Therefore, we decided that the Plan does not 
have to pre-approve repairs for a power wheelchair (K0108, K0739).
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 LTACH admission 
criteria, and the ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says the requested LTACH services do not meet the 
requirements for approval. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 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 Plan. The Plan has approved ongoing care in the 
current acute care setting.  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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio upper limb tremor stimulator and related 
supplies and accessories. 
 
You asked the Plan to pre-approve the limb stimulator and accessories. You say that you need this device for 
your health. You say that you are exhausted from taking medications for this condition, and this treatment is 
your last resort. The Plan denied your request. The Plan says the Cala Trio device is unproven and 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 the limb stimulator and accessories. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a diagnosis of Essential tremor. On January 10, 2023, it is 
documented that the enrollee's tremor was worsening in both hands. The enrollee has difficulty holding items 
and eating normally.  
 
 There is insufficient evidence supporting the use of the Cala Trio nerve stimulator device for the management 
of essential tremor. While 64% of patients reported having persistent relief for an average of 94 minutes, study 
findings do not sufficiently support that the Cala Trio's clinical benefits are sustained beyond three months. The 
available published studies do not compare Cala Trio to other treatment regimens for essential tremor. As such, 
this device is not currently considered medically reasonable and 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 limb stimulator and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Cala Trio upper limb tremor stimulator and related supplies and 
accessories.
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 requires mid-to-long term 
acute care for medically complex care on an ongoing basis. The Plan denied your request. The Plan will 
continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition 
is stable for transfer to an alternate level of care, or until the clinical circumstances change such that LTACH 
may be reconsidered. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
19, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 19, 
2022.
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 you need therapy to get stronger to get to where you 
were before. The Plan denied your request. The Plan says your records do not show that you have a complex 
rehabilitation need which would require you to be seen 3 times per week for evaluation of your functional goals 
and progress, services you need can be provided safely in other settings, a skilled nursing facility, home with 
home health services or home with outpatient therapy. 
 
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 there is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair from an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs the equipment. The Plan 
denied your request. The Plan says the services are available from network providers. 
 
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 a Group 2 power wheelchair from an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
You asked the Plan to pre-approve Otezla. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested medication does not fall under Part B coverage. The Plan says 
that they do not administer pharmacy benefits for the enrollee. 
 
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 Otezla.  
 
Benefits for Otezla 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: 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 September 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 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 
September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease testing (bacterial or viral respiratory 
tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets (0223U) provided on May 28, 2022. 
 
You asked the Plan to pay for the infectious disease testing, 22 targets. You say that this testing was denied in 
error. The Plan denied your request. The Plan says panel testing of greater than five respiratory pathogens are 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panel testing of more than five respiratory 
pathogens will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infectious disease testing, 22 targets have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious disease testing (bacterial or viral respiratory tract infection), pathogen-
specific nucleic acid (DNA or RNA), 22 targets (0223U) provided on May 28, 2022.