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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the member does not have clinical conditions that cannot be appropriately 
treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage. 
The plan will continue to cover medically necessary acute and critical care at the current facility until the 
member's condition is stable for transfer to an alternate level of care (such as a skilled nursing facility). 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this time. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revita skin substitute (Q4180). 
 
You asked the Plan to pre-approve Revita skin substitute. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show that the enrollee has failed treatment with standard 
wound care for four weeks or longer prior to the use of a skin substitute. 
 
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 Revita skin substitute. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary 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 Revita skin substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Revita skin substitute (Q4180).
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 (tilt/recline, legrests), 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 the enrollee does not have 
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 documentation does not show 
that the enrollee has a 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 (tilt/recline, legrests), and accessories.
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 this is medically necessary. The Plan denied your 
request. The Plan says your request does not meet Medicare guidelines because you no longer require skilled 
services on a daily inpatient basis and the continuation of SNF is not medically necessary. 
 
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 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 and/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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure addresses vertebrogenic 
pain by addressing a gap in the treatment algorithm for those suffering from chronic low back pain. You also 
say that the enrollee has tried and failed conservative treatments without relief. The Plan denied your request. 
The Plan says the records do not show that the source of the enrollee's pain is compatible with vertebrogenic 
pain. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease or stenosis. The reviewer also found that the provided documentation 
does not show a clear cause for the enrollee's pain. Therefore, the reviewer found that the requested Intracept 
procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (98511) in a facility. 
 
You asked the Plan to pre-approve a sleep study in a facility. You say that an in-lab study is medically 
necessary. You say that the enrollee has a moderately severe sleep apnea based on the home sleep testing done 
on July 19, 2023, which showed an REI = 21.9. The Plan denied your request. The Plan says a sleep study can 
be safely provided in the enrollee's home. 
 
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 sleep study in a facility. Our reviewer 
says that the requested in-lab sleep study is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that the enrollee does not meet requirements 
for an in-lab sleep study. Therefore, the reviewer found that the requested in-lab sleep study 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 sleep study in a facility have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sleep study (98511) in a facility.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on August 7, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
you were treated in your home and did not want to risk going to the hospital and getting any illnesses. The Plan 
denied your request. The Plan says without transport there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 7, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on August 7, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral device, coded E0486. 
 
You asked the Plan to pre-approve the requested device. You say that the appliance could improve your sleep 
experience.  The Plan denied your request. The Plan says that you do not meet the requirements for the 
requested device.  
 
The Plan follows Medicare rules. Medicare rules say that oral appliances for obstructive sleep apnea are 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 device. Our physician 
reviewer found that you have a longstanding history of obstructive sleep apnea. Recently, you complained of 
difficulty tolerating CPAP, and requested an oral device. The most recent sleep test was a home-based test on 
August 2, 2023. The AHI was 18.8 and the RDI was 24.8. On a previous sleep test in May 2014, the RDI was 
56.  However, you weighed slightly more at that time. The documentation shows that you do meet Medicare 
criteria for a mandibular advancement device, with a diagnosis of moderate obstructive sleep apnea, with AHI 
and RDI between 15 and 30. Documentation of CPAP intolerance is only required when the AHI or RDI is 
greater than 30. Therefore, the request is 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 requested device have been met. Therefore, we decided that the Plan has to 
pre-approve an oral device, coded E0486.  
 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the request is not medically necessary because the records show you 
are requesting services from a massage therapist. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs from February 14, 2023, through 
February 18, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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 pay for the self-administered drugs from 
February 14, 2023, through February 18, 2023.  
 
Benefits for the medication 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: 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 this care to regain 
maximum function. The Plan denied your request. The Plan says medical records do not support the need for 
an LTACH admission and, the enrollee needs can be provided at another 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 the enrollee's care can be safely provided at the current facility until they are more 
stable and appropriate for transfer to another level of care. Completion of treatment at the current facility is 
recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 14, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that medical records were provided. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a combined cardio and pharmacogenetics test panel was provided. We looked at the file and 
Medicare rules. This NGS panel was not billed with a single code as required. Additionally, the provided 
testing was reportedly ordered to make decisions about the enrollees medications. Medications should be 
provided based on the presence of a diagnosis and should be adjusted based on a response to the medication. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on April 14, 2023, billed with codes 
81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, and 81238.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty extra-wide hospital bed (E0303). 
 
You asked the Plan to pre-approve a hospital bed. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you do no meet the weight requirement for this bed. 
 
The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed E0303 is covered 
if the the beneficiary's weight is more than 350 pounds but does not exceed 600 pounds and meets one of the 
criteria for a fixed height hospital bed.  
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a heavy-duty extra-wide hospital bed (E0303).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and the localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided 
on February 8, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental services provided are not covered 
by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) and 
the localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per 
tooth (D4381) provided on February 8, 2023.
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 IRF services so you can continue to get 
stronger and be safe at home. The Plan denied your request. The Plan says you do not meet the requirements 
for an IRF admission.  
 
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 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 the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation program provided in an 
IRF. 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: 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 LTACH care is necessary The Plan 
denied your request. The Plan says LTACH is not reasonable and necessary. 
 
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 patient 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. 
 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 pneumatic compression device (E0652) and 
accessories (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the provider did not document at least 4 weeks of 
regular, daily, multiple hour home usage of the basic pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and accessories (E0656, E0667).