Persius/hicric huggingface dataset:
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. You say that this is a covered benefit. The 
Plan denied your request. The Plan says durable medical equipment in a skilling nursing facility (SNF) is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a Group 3 power wheelchair is being requested for use in a SNF or hospital. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of Minuteman device. 
 
You asked the Plan to pre-approve a Minuteman device. You say that the enrollee has completed over six 
months of conservative treatment. You say that the enrollee's pain is progressively getting worse. You also say 
that this is medically necessary for the enrollee. The Plan denied your request. The Plan says this is 
experimental and therefore is not covered. 
 
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 Minuteman device. Our reviewer says 
that the requested Minuteman device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft 
material and is not intended for stand-alone use. The documentation does not corroborate plans for use of bone graft in this procedure. In addition, fusion indications within guidelines/literature for (existing or potential 
intraoperative) instability have not been documented and/or met in this case. The magnetic resonance imaging 
was noted in an exam; however, the formal report was not provided for review to corroborate pathology at the 
requested surgical level. In addition, there are multiple alternate pain generators plausibly significantly 
contributing to the clinical condition that have not been fully documented as having been excluded and/or ruled 
out. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the reviewer found that the requested Minuteman device at L4-5 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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of Minuteman device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need this care to regain strength and endurance. 
The Plan denied your request. The Plan says you no longer require SNF care and continued services are 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 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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a continuous glucose monitor (CGM).  
You asked the Plan to pay for  a CGM. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the enrollee is not on insulin and does not have documentation of problematic 
hypoglycemia. 
 
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 a CGM. Our reviewer says that the item is 
not medically necessary. Our physician reviewer found the enrollee is not on insulin and does not have 
documentation of problematic hypoglycemia. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pay for  a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustable bed provided on July 24, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for the OON services. You say that your doctor recommended this bed. The Plan 
denied your request. The Plan says the bed is not eligible for reimbursement. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The file shows that an adjustable bed was provided for chronic back pain. We looked at the file and the rules. 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. The 
bed was not provided because you have a medical condition which requires positioning of the body in ways not 
feasible with an ordinary bed; or you require attachments which can only be attached to a hospital bed; and you 
require frequent changes in body position and/or has an immediate need for a change in body position. The 
provided bed is not considered a hospital bed suitable for coverage/payment. Medicare rules say that a total 
electric hospital bed is not covered. We found no exception that would require the Plan to pay for these items. 
Therefore, we decided that the Plan does not have to pay for the adjustable bed provided on July 24, 2023, by 
an out-of-network (OON) provider.
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 June 30, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary and there were no beds available at the hospital. 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 June 30, 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 June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tempus xF testing. 
 
You asked the Plan to pre-approve Tempus xF testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of Tempus xF testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Tempus xF testing.
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 the enrollee needs SNF care. The Plan denied your 
request. The Plan says the requested service is not medically necessary as the enrollee has no documented 
skilled therapy needs. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: 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 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 IRF 
admission and, the enrollee needs can be safely provided at another setting.  
 
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 the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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: 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee can safely receive the services they need in other settings, for 
example a skilled nursing facility (SNF), or at home with home health and home physical therapy.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does 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. 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 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 SNF care is necessary. The Plan denied your 
request. The Plan says SNF care is not reasonable and 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 the patient no longer requires the level of observation and treatment provided in 
terms of physician oversight and skilled nursing care. The patient is medically stable and is tolerating oral 
medications. The patient does not require daily skilled nursing services, including complex wound 
management, tracheostomy care, bowel and bladder training and tube feeding, or administration of intravenous 
(IV) medications. The patient may continue to benefit from occupational and physical therapy and assistance or 
supervision. However, this does not require the intensity of skilled therapy services provided in the skilled 
nursing facility setting. Therefore, the continued skilled nursing facility care 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 enrollee needs this care to optimize mobility and 
strength. The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria 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 the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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: 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 enrollee needs to return to their prior level of 
function where they were independent living in a multi-level home. You say that the enrollee requires 
assistance and training with activities of daily living. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary.  
 
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 enrollees 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: 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 are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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 the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
requires treatment by multiple therapies, including physical therapy and occupational therapy, but this can be 
provided in a lower level of care. There is documentation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF, but the services required can 
be provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on July 15, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
your friend called the ambulance, and they suggested you call your doctor since the hospital would have been 
unable to help you. 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 July 15, 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 July 15, 2023.