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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not able to care for yourself and you do not 
feel safe being alone at home. The Plan denied your request. The Plan says you do 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 complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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 an IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 10 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services 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 therapy services. 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 enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore are 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 10 physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213-25) provided on September 8, 2022. 
 
You asked the Plan to pay for the office visit. You say that reconsider the denied charges with the submitted 
medical records. The Plan denied your request. The Plan says the payment the Plan already made for the 
surgery includes the benefit for the pre-operative, post-operative and same day visits.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the office visit. Our reviewer found the medical records 
provided indicates procedure 11721 was performed on September 8, 2022. The surgery payment includes 
benefit for pre-operative, post-operative and same day visits. The medical records do not include sufficient 
documentation to validate that 99213 was a distinct, separate service, therefore this procedure is not eligible for 
additional reimbursement.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visit (99213-25) provided on September 8, 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 have very severe limited function in your 
walking and standing. You say the staff at the skilled nursing facility evaluated you and feel you are a good fit 
for the program for your recovery. The Plan denied your request. The Plan says the IRF services requested do 
not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vocal feminization surgery (Wendler Glottoplasty) 
(31599).  
 
You asked the Plan to pre-approve the surgical procedure. You say that you require surgery to remove 
masculine features and match your features and voice to your actual gender. The Plan denied your request. The 
Plan says this request for vocal feminization surgery (Wendler Glottoplasty) is not covered because your 
records show you do not have injury or malformation to your vocal cords.  
 
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 surgical procedure. 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 a diagnosis of gender identity disorder. Examination of the vocal cords on January 17, 2023, did not reveal any focal lesions. It is documented that the enrollee has demonstrated 
good improvement in pitch and feminine resonance with use of techniques taught in therapy. Medicare 
provides coverage for surgery used to repair areas of the body affected by trauma, disease, or developmental 
defects. The documentation does not support that the requested surgery is medically reasonable and necessary 
for the enrollee 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 the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve vocal feminization surgery (Wendler Glottoplasty) (31599).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at an alternate level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. 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 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 backup portable power wheelchair. 
 
You asked the Plan to pre-approve a backup portable power wheelchair. You say that you are bed ridden and 
the power wheelchair that you use is too heavy. You also say that your caregiver cannot take it with them 
because the wheelchair does not fit since it is too heavy, and is only for inside the house. The Plan denied your 
request. The Plan says the notes do not show that there is further clinical justification to support medical 
necessity of the requested item. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 
 
 
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a backup portable power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, is stable 
for transfer to the IRF, and their needs cannot be met at a lower level of care. The Plan denied your request. 
The Plan says the enrollee does not meet Medicare guidelines for services in 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 complexity of the enrollee's 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 therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are unable to ambulate or utilize 
lesser equipment to meet their mobility needs. You say that you require this level of equipment to meet 
medical, functional, mobility, pressure relief, and spasticity management needs throughout the day in your 
home. The Plan denied your request. The Plan says the notes do not show a medical need to control the power 
options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates that you have adequate strength to manage 
standard power drive controls as you are able to eat and groom independently. Therefore, the reviewer found 
that the request for upgraded electronics 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the ventilator is not necessary. 
 
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 home ventilator. Our physician 
reviewer found there is no documentation in the record of a neurological examination, muscle strength testing, or testing of inspiratory force. Pulmonary function testing indicates severe combined restrictive and obstructive 
lung disease. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. If this enrollee does 
have chronic carbon dioxide (CO2) retention, may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep as an outpatient. This has not been tried and 
shown to fail. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0466). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that this type of bed is medically 
necessary due to hemiplegia, unspecified affecting right dominant side. The Plan denied your request. The Plan 
says the documentation does not indicate that the enrollee requires frequent and immediate need for a change in 
body position to qualify for a semi-electric hospital bed.   
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found that the documentation 
does not reveal that the enrollee's condition requires position changes of the body in ways not feasible in an 
ordinary bed. The enrollee does not require immediate or frequent changes in body position. The enrollee's 
condition does not require special attachments that cannot be fixed and used on an ordinary bed. The semi-
electric hospital bed is not medically necessary for this enrollee. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the ventilator is not necessary. 
 
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 home ventilator. Our physician 
reviewer found there is no diagnosis of thoracic restrictive disease or neuromuscular disease. There is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide (CO2) retention.  If that is 
present, may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure 
support (AVAPS) during sleep. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 40 Amp Nano Silica Interceptors (K0108 x2), elbow 
positioning support pads (K0108 x2), stealth height adjustable receiver (K0108), electronic connection 
(E2311), harness (E2313), expandable controller (E2377), and attendant control (E2331). 
 
You asked the Plan to pre-approve a 40 Amp Nano Silica Interceptors, elbow positioning support pad, stealth 
height adjustable receiver, electronic connection, harness, expandable controller, attendant control. You say 
that when three or more power seating functions/actuators/motors are provided, one unit of E2311, one unit of 
E2377, and one unit of E2313 are allowed. You also say that the enrollee requires immediate approval of the 
requested equipment to enable them not to have increased medical conditions. The Plan denied your request. 
The Plan says the battery (K0108) and elbow positioning support pads (K0108) are miscoded, and the arm rest 
assembly (K0108) is a duplicate service that cannot be covered. The Plan also says that there is not a medical 
need to control the power options through the joystick, and an attendant control cannot be covered in addition 
to a beneficiary-operated joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a 40 Amp Nano Silica Interceptors, 
elbow positioning support pad, stealth height adjustable receiver, electronic connection, harness, expandable 
controller, attendant control. 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 adequate strength to 
manage standard power drives. The expandable controller and associated electronics are not medically 
necessary. Our reviewer also found that the items coded in the request as K0108 are unbundled and miscoded. 
 
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 40 Amp Nano Silica Interceptors, elbow positioning support pad, stealth 
height adjustable receiver, electronic connection, harness, expandable controller, attendant control have not 
been met. Therefore, we decided that the Plan does not have to pre-approve 40 Amp Nano Silica Interceptors 
(K0108 x2), elbow positioning support pads (K0108 x2), stealth height adjustable receiver (K0108), electronic 
connection (E2311), harness (E2313), expandable controller (E2377), and attendant control (E2331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seat scissors (K0108), a push tracker (K0108), and push 
handles (K0108). 
 
You asked the Plan to pre-approve the seat scissors, push tracker, and push handles. You say that the requested 
items are medically necessary. The Plan denied your request. The Plan says the requested items do not meet the 
definition of durable medical equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that items that do not meet Medicares definition of 
DME are not covered. 
 
 The requested items do not meet Medicares definition of durable medical equipment. Therefore, we decided 
that the Plan does not have to pre-approve seat scissors (K0108), a push tracker (K0108), and push handles 
(K0108).