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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet medical necessity 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 document does not support necessity for admission to an IRF. The 
complexity of the enrollee's nursing, rehabilitation, and medical needs does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the enrollee may 
benefit from physical therapy and/or occupational therapy, the enrollee's rehabilitation needs can be provided in 
a lower intensity and 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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two mohs micrographic procedures provided on August 
11, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the mohs micrographic procedures. You say that it was not possible for the 
enrollee to obtain these services from an in-network provider. The Plan denied your request. The Plan says 
enrollees must receive their care from a network provider. 

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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the two mohs micrographic procedures provided 
on August 11, 2022, by an out-of-network (OON) provider.
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 requires daily physician oversight, 
continuous nursing, physical therapy, and occupational therapy.  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 the clinical documentation does not specify any active medical comorbidities or 
complex functional impairments. Thus, the complexity of the enrollees documented nursing, medical, and 
rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The clinical documentation shows that the enrollee requires ongoing skilled 
therapy but does not show that the enrollee would require an intensive rehabilitation regimen. IRF criteria are 
not met. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 25, 2022, billed with 
codes 81266 and 81265. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have attached the pathology report 
along with this letter and you request reconsideration and reprocessing of your claim towards payment. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim.  The 
know error DNA Specimen Provenance Assay is a statutorily excluded test. 
 
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.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 25, 2022, billed with codes 81266 and 81265.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #3 provided on December 
8, 2022. 
 
You asked the Plan to pay for the dental service. You say that it was medically necessary to get the procedures 
done because you did not want the tooth to continue to decay. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the core buildup is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #3 provided on December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ZooMe AutoFlex Folding Travel Scooter (K0899). 
 
You asked the Plan to pre-approve the ZooMe AutoFlex Folding Travel Scooter. You say that you need this 
item. The Plan denied your request. The Plan says the information submitted does not explain what features of 
the requested item are unavailable in a brand name scooter, or why they are necessary to avoid an adverse 
medical outcome.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment 
(DME) to only those preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ZooMe AutoFlex Folding Travel Scooter have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the ZooMe AutoFlex Folding Travel Scooter (K0899).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliances 
(E0673 x) and pneumatic compression device (E0675) provided on October 6, 2022. 
 
You asked the Plan to pay for the segmental gradient pressure pneumatic appliances and pneumatic 
compression device. You say that you believe there is a misunderstanding on the place of service codes. You 
also say that the durable medical equipment was prescribed during the enrollees surgery. The Plan denied your 
request. The Plan says The Plan also says the Place of Service billed was 22, which is an outpatient hospital. 
The Plan also says the pneumatic compression devices (E0673 and E0675) were billed for use outside of the 
home and are not separately payable. 
 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 pay for the segmental gradient pressure pneumatic appliances (E0673 x) and pneumatic 
compression device (E0675) provided on October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ice machine. 
 
You asked the Plan to pre-approve an ice machine. You say that you were advised you needed to ice your knee 
two to three times per day following your knee surgery. You say that you are not able to get up ad go to the 
fridge to get ice. You say that if you try to get up you are in a lot of pain. You also say that you have surgery 
scheduled for your other knee in three months and will need ice then too. The Plan denied your request. The 
Plan says the requested Ice machine is a convenience item and therefore is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal 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.  Therefore, we 
decided that the Plan does not have to pre-approve an ice machine.
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 will require another three to 
four weeks to continue complex respiratory medical care, daily multi-specialty physician follow-up, daily labs, 
and physical and occupational therapy. The Plan denied your request. The Plan says the IRF care is not 
medically necessary, and the enrollee's needs can be met in a lower level of care such as a skilled nursing 
facility, home with home health services, or outpatient 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 was admitted following a fall and found to have chronic obstructive pulmonary disease (COPD) exacerbation with acute on chronic hypoxic and hypercapnic respiratory 
failure. The record indicates that the enrollee has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that she is not currently receiving but that would be 
available at the LTACH facility.  
 
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: 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 your physician recommends comprehensive 
intensive stroke therapy so you can safely return home. The Plan denied your request. The Plan says your 
records show you were acutely ill with a significant decline in your baseline function due to your stroke. 
Services needed can be provided safely in a skilled nursing facility. 
 
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. 
 
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 Dexcom G6 Mis sensor. 
 
You asked the Plan to pre-approve the Dexcom G6 Mis sensor. The Plan denied your request. The Plan says 
the enrollee is not on insulin, nor a history of hypoglycemic events. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the Dexcom G6 Mis sensor have not been met.  Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G6 Mis sensor.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid provided on 
January 03, 2023. 
 
You asked the Plan to pay for infectious agent detection by nucleic acid. You say that this service is supported 
in the records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for infectious agent 
detection by nucleic acid provided on January 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injections do not meet the 
Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules.  
 
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 facet joint injections. Our reviewer says 
that the requested facet joint injections are not considered medically necessary in this case. Our physician 
reviewer found that in this case, the enrollee's provider has requested therapeutic intraarticular facet joint 
steroid injections at bilateral L3-L4, and L4-L5. There is no documentation this enrollee has undergone two 
sets of diagnostic facet procedures at these sites. There is no documentation why the enrollee is not a candidate 
for radiofrequency ablation. The order submitted by the provider's office states this is the enrollee's first set of 
therapeutic intra-articular facet joint injections and the enrollee has not had diagnostic medial branch blocks. 
The review has determined that the requested facet joint injections do not meet the Medicare LCD coverage 
criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. 
 
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 adult sized disposable incontinence product (T4526). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need these items due to your severe 
incontinence. You also say that your problem started 5 years ago when the urologist removed your large 
prostate cancer. The Plan denied your request. The Plan says incontinence supplies are not a Medicare covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve adult sized disposable 
incontinence product (T4526).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional routine transportation miles. You say that you have limited 
mobility and have no one else to rely on for medical appointments. The Plan denied your request.  The Plan says the documentation indicates that the distance is over the 30-mile limit therefore, this is outside 
the benefit for routine transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when transportation, such as a wheelchair van, is ONLY covered 
when it is medically necessary and in very limited circumstances. An authorization is required for non-
emergency transportation. Routine trips are limited to 30 miles from pick-up point to destination point in your 
state.  
 
We looked at your request, the records in the case file, and the rules. You are requesting a trip that is over the 
30-mile limit.  Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation miles.