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

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), expandable controller (E2377), and backup camera (K0108). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, expandable 
controller, and backup camera. The Plan denied your request. The Plan says the electronic connection, 
expandable controller harness, and expandable controller cannot be covered as it is not medically necessary to 
control the three requested power options through the joystick (drive interface). The Plan also says a backup 
camera does not serve a medical purpose and cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 an electronic connection, expandable 
controller harness, and expandable controller. 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 
paraplegia and uses a slide board transfer with modified independence. Our reviewer also found that the 
electronic connection, expandable controller harness, and expandable controller are not medically necessary as 
the enrollee has adequate strength to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. The requested backup camera 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. Based on this information, we decided that Medicare rules for 
coverage of an electronic connection, expandable controller harness, expandable controller, and backup camera 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection 
(E2311), expandable controller harness (E2313), expandable controller (E2377), and backup camera (K0108).
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving the care needed in the current 
hospital. 
 
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 the enrollee's documentation does not support that LTACH services are medically 
appropriate currently.  
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on May 19, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the Cxbladder test (0013M) provided on May 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Optimizer Smart implantable pulse generator (0408T). 
 
You asked the Plan to pre-approve the Optimizer Smart device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of this device has not 
been demonstrated in the peer-reviewed literature. 
 
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 Optimizer Smart device. Our 
reviewer says that the requested Optimizer Smart device is not considered medically reasonable and necessary 
in this case. Our physician reviewer found that this device is experimental. The reviewer found that large 
multicenter randomized controlled trials are required. Therefore, the reviewer found that the requested 
Optimizer Smart device 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 Optimizer Smart device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Optimizer Smart implantable pulse generator (0408T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 17, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says there is a more 
comprehensive code for the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The testing in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on August 17, 2023.
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 needs pulmonary 
rehabilitation to wean from a bi- pap, daily physician visits, 24-hour nursing and wound care. The enrollee's 
complex needs cannot be met at a lower level of care. The Plan denied your request. The Plan says it is not safe 
to leave the hospital at this time because the enrollee's kidney function is not stable, and breathing is worse. 
The Plan says the enrollee is receiving the care you need in the hospital where you are now. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another. 
 
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: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
August 11, 2023, to August 14, 2023. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with the 
copayment. 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 $175 
copayment for outpatient hospital services/Medicare-coveredoutpatient hospital surgery services. 
 
You have been asked to pay a $175 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital services/Medicare-coveredoutpatient hospital surgery 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. The total amount you awe 
is $350 ($175 x 2 visits = $350). Therefore, we decided that the Plan does not have to waive the copayment for 
outpatient hospital services provided on August 11, 2023, to August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous glucose monitor (CGM) 
supplies provided on September 05, 2023. 
 
You asked the Plan to waive the coinsurance for the continuous glucose monitor (CGM) supplies. You say that 
the cost share is wrong. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the continuous glucose monitor (CGM) supplies. This 
item/service falls within the durable medical equipment (DME) and related supplies 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 the continuous glucose monitor (CGM) supplies provided 
on September 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0861) and accessories (E2377, 
E2313, E2323, E1028x5, E1007, E2300, E1012, E2311, K0108x6, E2331, E0953, E0960, E2615, E0955, 
E2624, E2209, E2361). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for a base code power 
wheelchair group 3 with multiple power options. 
 
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 power wheelchair and accessories. 
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 Guilian-Barre syndrome with exacerbation. He has had 
the condition for over 20 years. Per L33789, the enrollee does not have a high risk for skin breakdown, use a 
catheter intermittently, have spasticity or require an alternative means of managing power drive. Therefore, the 
enrollee does not meet criteria for the requested wheelchair and accessories. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair (K0861) and accessories (E2377, E2313, E2323, 
E1028x5, E1007, E2300, E1012, E2311, K0108x6, E2331, E0953, E0960, E2615, E0955, E2624, E2209, 
E2361).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Freestyle Libre 3 Sensor (A9276).  
You asked the Plan to pay for Freestyle Libre 3 Sensor. You say that this is medically necessary to monitor 
blood glucose levels. The Plan denied your request. The Plan says they determined that the use of this device is 
not reasonable and necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for Freestyle Libre 3 Sensor. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found coverage criteria for continuous 
glucose monitors require insulin use or low blood sugar. Our physician reviewer also found that although the 
Freestyle Libre 3 Sensor may help the enrollee, the criteria for this coverage are not met at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Freestyle Libre 3 Sensor have not been met. Therefore, we decided that the Plan 
does not have to pay for Freestyle Libre 3 Sensor (A9276).
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 been doing phenomenally at the current 
facility and you are ready and able to participate in the more rigorous level of therapy so you can continue 
working on your mobility and balance. You also say that you worry you will fall if you don't get stronger, 
which the acute therapy will help you do The Plan denied your request. The Plan says based on Medicare 
guidelines, the IRF services you 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 the clinical documentation does not specify any active medical comorbidities 
(medically stable in SNF) or complex functional impairments thus the complexity of your documented nursing, 
medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. Clinical documentation supports the need for on-going skilled 
therapy but does not support the medical necessity of an intensive rehabilitation regimen in an IRF 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 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 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that this 
is medically necessary for the enrollee. The Plan denied your request. The Plan says there is not a medical need 
for multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria are met. 
 
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 Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided records indicate the enrollee 
does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. Therefore, the reviewer found that the requested Group 3 power 
wheelchair with multiple power options 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 a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options and accessories.
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 admission is medically necessary for the 
enrollee and currently in the hospital and ready for discharge. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient 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 documentation does not support that LTACH services are medically appropriate 
currently. 
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facility-based polysomnography (95810) and 
continuous positive airway pressure (CPAP) titration (95811). 
 
You asked the Plan to pre-approve the outpatient services. You say that you were told you needed a new sleep 
study done to get supplies for your CPAP machine. You say that you were told your previous sleep study 
would not be sufficient. You also say that this should be covered since you have sleep apnea and benefit from 
having a CPAP machine. The Plan denied your request. The Plan says the records do not show clinical signs 
and symptoms indicative of obstructive sleep apnea (OSA), and do not have any comorbidities that indicate a 
need for a facility-based sleep study. 
 
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 outpatient services. Our reviewer says that the requested repeat sleep study testing is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records support a diagnosis of obstructive sleep apnea (OSA) 
and that you are compliant with continuous positive airway pressure (CPAP) therapy. The reviewer found there 
is no indication of repeat testing to obtain supplies for CPAP maintenance and thus no indication for repeat 
sleep study testing. Therefore, the reviewer found that the requested repeat sleep study testing 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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facility-based polysomnography (95810) and continuous positive airway pressure 
(CPAP) titration (95811).
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 this is necessary for the enrollee to gain upper body 
strength. You say that the enrollee's antibiotic schedule make home health difficult. You also say that a skilled 
nursing facility would not appropriately address the enrollee's needs. The Plan denied your request. The Plan 
says the enrollee's needs can be met at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that 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. Therefore, the reviewer found that the requested IRF 
admission is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.