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

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair and 
controller (E2311), a harness for upgrade to expandable controller (E2313), and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve codes E2311, E2313, and E2377. You say that the medical records provided 
support the need for items which remain in dispute. The Plan denied your request. The Plan says the items 
which remain in dispute 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 codes E2311, E2313, and E2377. Our 
reviewer says that the items which remain in dispute are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has adequate strength on the left to manage standard 
switches on a power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes E2311, E2313, and E2377 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection between wheelchair and controller (E2311), a 
harness for upgrade to expandable controller (E2313), and an expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VASS (L5781). 
 
You asked the Plan to pre-approve the system. You say that the VASS is medically necessary. The Plan denied 
your request. The Plan says there are not enough medical studies to show the vacuum socket system is better than a standard socket for a prosthetic leg. The Plan states there are not enough medical studies to show the 
vacuum socket system will help in the enrollee's care. 
 
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 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 had a recent replacement socket with a lower extremity prosthesis. The 
requested device has not been shown to be superior to other standard treatments for the medical condition. The 
requested VASS for the prosthesis is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve VASS (L5781).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crowns (D6066 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are 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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant 
supported crowns (D6066 x 2).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional transportation mileage. You say that you need to have bariatric 
surgery at the location requested. You also say that this surgery is urgent and important to your health. The 
Plan denied your request. The Plan says this request exceeds the benefit limit. 
 
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 each one-way trip does not exceed 50 miles of driving 
distance.   
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, this request exceeds 
the allowed benefit limit of 50 miles of driving distance. Therefore, we decided that the Plan does not have to 
pre-approve additional transportation mileage (A0170).
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. The Plan denied your request. The Plan says the enrollee will not 
be able to take part in 3 hours of therapy a day. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital with chest pain, shortness of breath, diarrhea, fever, 
and generalized weakness. She was found to have damage to her heart, low blood pressure, and trouble 
breathing. The enrollee is able to get out of bed with assistance from a therapist, but tires very quickly.  There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. The enrollee does not require treatment by 
multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy 
program. Therefore, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to regain more strength and mobility 
so that you can be safely transferred to the next phase of your recovery. The Plan denied your request. The Plan 
says a SNF admission is not medically necessary, and your needs can be met at a lower level of care. 
 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. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME). 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the coinsurance. 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 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME is $946.56. 
You are being asked to pay $189.31 ($946.56 x 20% = $189.31). This item/service falls within the durable 
medical equipment (DME) 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 coinsurance for durable 
medical equipment (DME).
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. The Plan denied your request. The Plan says the enrollee does not 
have the endurance to participate in intensive therapies for 3 hours per day. 
 
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 physician reviewer found 
that the complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care.  
 The enrollees medical status does not require intensive physician and nursing oversight in an IRF. While the 
enrollee may benefit from additional therapies, including physical and occupational therapy, the documentation 
does not reveal that the patient requires or can tolerate this therapy on an intensive IRF level. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal tooth #18 
(D2750). 
 
You asked the Plan to pre-approve the crown - porcelain fused to high noble metal tooth #18 (D2750). The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
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. The Plan covers the crown - 
porcelain fused to high noble metal tooth #18 (D2750) when the services are medically necessary and 
reasonable.  
 
 
 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 crown - porcelain fused to high 
noble metal tooth #18 (D2750). Our reviewer says that the service is not medically necessary. Our physician 
reviewer found there was no narrative indicating why a replacement crown is necessary. Due to the poor 
quality of the radiographs, a determination if recurrent caries was present could not be determined. The 
documentation provided does not meet the criteria for coverage for a replacement crown (D2750) for tooth #18. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown - porcelain fused to high noble metal tooth #18 (D2750) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused to high 
noble metal tooth #18 (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 You asked the Plan to pre-approve the requested services. You say that the wound is not healing very well. The 
Plan denied your request. The Plan says you do not have a covered indication. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that you were diagnosed with metatarsal head osteomyelitis and underwent a transmetatarsal 
amputation. You have adequate blood flow. The review has determined that you have dehiscence of the 
surgical wound and a pressure wound. These are not covered indications for hyperbaric oxygen therapy. 
Therefore, the requested treatment is not indicated for the your condition. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation oncology treatment to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve radiation oncology treatment. You say that the recommended procedure has 
more risk. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and you 
can be treated within the Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
radiation oncology treatment to be provided by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says the enrollee's 
rehabilitation needs are not complex. 
 
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 physician reviewer found 
that the enrollee was admitted to the hospital with loss of consciousness.  The therapy notes state the enrollee 
can tolerate 10-20 minutes exercise with multiple rests and is limited by fatigue. The complexity of the 
enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care.  The enrollee does not require treatment by multiple therapies, including either physical or occupational 
therapy, in an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on  
November 3, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you have not been charged for 
this service in the past. 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 $30 
copayment for lab services and diagnostic procedures/tests performed in an in-network outpatient hospital 
facility.  
 
You have been asked to pay a $30 copayment for laboratory services. This item/service falls within the lab 
services and diagnostic procedures/tests performed in an in-network outpatient hospital facility 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 laboratory services provided on November 3, 
2022.
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's needs have been met and 
stabilized in the acute care setting, as they are stable for transfer to an LTACH for a continuation of care. The 
Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee's 
needs can be provided 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 there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving 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 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 Dexcom G6 sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 sensor. You say that the enrollee needs a device that will send 
alerts with high/low blood sugars. The Plan denied your request. The Plan says the enrollee does not require 
insulin three or more times daily. 
 
 
 
 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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 Mis sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 sensor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve the 6 additional physical therapy visits. You say that the records provided 
support the need for the total number of physical therapy visits requested. The Plan denied your request. The 
Plan says the additional physical therapy visits which remain in dispute are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 6 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy 
generally is not accepted as specific and effective therapy for the patient condition beyond what was approved 
by the health plan. The patient has had prior extensive therapy approved and the documentation does not reveal 
that the patient requires the ongoing unique skills of a professional therapist to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the patient's current condition or to prevent or slow further deterioration. The patient can 
safely transition to an independent home exercise program with the already approved therapy. 
 
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 6 additional physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 6 additional physical therapy visits.