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

 
We decided that the Plan has to pay for the transcutaneous electrical nerve stimulator (TENS) device (E0730) 
provided December 3, 2021. 
 
You asked the Plan to pay for the TENS device. You say that all services ordered are medically necessary and 
meet the criteria per Medicare National Policy, LCD L33802. The Plan denied your request. The Plan says that 
Medicare payment for chiropractor services is limited to treatment by means of manual manipulation of the 
spine to correct a subluxation. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 the TENS device. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic neck and upper back pain. This is an accepted indication for a trial of 
TENS. The unit was 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 TENS device have been met. Therefore, we decided that the Plan has to pay 
for the transcutaneous electrical nerve stimulator (TENS) device (E0730) provided December 3, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF criteria and requires intensive 
inpatient rehabilitation with daily physician management, continuous rehabilitation nursing, and intensive 
therapies to optimize mobility and strengthening while ensuring the restoration of their functional status for a 
safe and sustainable discharge. The Plan denied your request. The Plan says 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that the enrollee has had functional and clinical 
status changes thus would be expected to require continued assessment by skilled nursing and skilled therapy. 
Clinical documentation shows that the enrollee is moderate to maximum assist with mobility and self-care tasks 
and evaluating therapists recommend daily skilled therapy in a SNF setting. Clinical documentation shows that 
enrollee's prior level of function (PLOF) was moderate I with mobility tasks in April 2023, and has had 
recurrent infections and multiple hospitalizations since this time period thus currently beneath functional 
PLOF. Clinical documentation shows that the enrollee requires close respiratory assessment status post-acute 
pneumonia, multiple laboratory draws, and labile blood pressure thus would be expected to require frequent 
assessment by skilled nursing. Clinical documentation supports daily skilled services. From a practical 
standpoint, clinical documentation does support daily skilled services on an inpatient basis in a skilled nursing 
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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: 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 treatment for the infection in your heart, 
and you need physical therapy because you are unable to do a lot of the normal functions you are usually able 
to do. The Plan denied your request. The Plan says the request for IRF services does 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The clinical 
documentation shows that you require ongoing skilled physical and occupational therapy however, it does not 
support 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat Supartz FX injection. 
 
You asked the Plan to pre-approve a repeat injection. You say that the enrollee has bilateral knee osteoarthritis. 
You say that the enrollee has had cortisone injections and successful viscosupplementation which lasted approximately six months. You say that the enrollee utilizes topical creams, home exercises and heat to provide 
relief. You also say that the enrollee's last injection was on January 9, 2023. The Plan denied your request. The 
Plan says a repeat injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat series of viscosupplement therapy is 
considered reasonable and necessary when all the criteria have been 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 repeat injection. Our reviewer says 
that the request for a repeat injection is not medically necessary. Our physician reviewer found the provided 
documentation indicates that the enrollee's last injection was more than six months ago. The reviewer also 
found that the documentation does not indicate that the enrollee had a response to the previous course of 
hyaluronic acid derivative therapy for osteoarthritis of the knee and now requires additional therapy for 
osteoarthritic symptoms. Therefore, the reviewer found that the request for a repeat injection 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 repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat Supartz FX injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of calculi/debris from biliary duct(s) and/or 
gallbladder (47544) provided on December 5, 2022. 
 
You asked the Plan to pay for removal of calculi/debris. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says the provider did not bill as 
required by Medicare coding regulations. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 47544 
(removal of calculi/debris) is an add-on code and has not been billed with an appropriate primary procedure 
code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the 
Plan does not have to pay for removal of calculi/debris from biliary duct(s) and/or gallbladder (47544) 
provided on December 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychology services provided on January 3, 2023, to March 
3, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for psychology services. You say that the enrollee would have needed to leave the 
facility to see a participating provider. The Plan denied your request. The Plan says the rendering psychologist 
is an out-of-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 item/service 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 psychology services provided on January 3, 2023, 
to March 3, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomographic (CT) scan of the chest. 
 
You asked the Plan to pre-approve the scan. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the requested CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that there is no 
abnormal imaging report of the thyroid or of the chest requiring further evaluation. The request states there is 
abnormal thyroid imaging but no report of same is in the records. There is a chest x-ray of 2022 showing no 
unusual findings. The medical necessity of the requested CT of the chest has not been demonstrated in the 
submitted records. 
 
 
 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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomographic (CT) scan of the chest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0843, 
E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2602). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says the enrollee does not have a 
qualifying diagnosis causing mobility limitation for which a group 3 power wheelchair is medically needed. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or  
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair and accessories (K0843, E0955, E1007, E1012, E1028, E2311, E2313, E2361, 
E2377, E2602).
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 had your third back surgery in 14 months. You 
say this is by far the worst one and will take the longest to recover from according to your surgeon. You say 
you both believe it would be dangerous for you to go home without having rehabilitation first. The Plan denied 
your request. The Plan says you do not meet Medicare guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 2, 2022, to March 30, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on March 
2, 2022, to March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair with a single power option and 
accessories. 
 You asked the Plan to pre-approve a Group 3 power wheelchair. You say that you need this power wheelchair 
for your mobility. You also say that you were forced to purchase a used powerchair and have fallen multiple 
times. The Plan denied your request. The Plan says that you do not have a medical need for a Group 3 power 
wheelchair with a single power option. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered if 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. Our 
reviewer says that a Group 3 power wheelchair is medically necessary. Our physician reviewer found the 
provided documentation indicates you are functionally non-ambulatory and cannot use a cane or walker for 
mobility. The documentation indicates you cannot functionally propel a manual wheelchair due to upper 
extremity weakness and cannot operate a power scooter due to impaired sitting balance. The reviewer found 
that you require a power wheelchair for mobility and accomplishing daily activities. The documentation 
indicates you are able to perform transfers, but you cannot sit independently and therefore needs a Group 3 
power wheelchair given your seating and positioning needs. Given your seating and positioning needs, a Group 
2 power wheelchair would not be appropriate. The reviewer found that you require the power tilt for adequate 
pressure relief given your right upper extremity paralysis. The reviewer also found that you require power 
elevating leg rests given your lower extremity edema. Therefore, the reviewer found that the requested Group 3 
power wheelchair with power tilt and power elevating leg rests is 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 a Group 3 power wheelchair have been met. Therefore, we decided that the Plan 
has to pre-approve a Group 3 power wheelchair with a single power option and accessories.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro (tirzepatide solution). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. 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 pre-approve Mounjaro (tirzepatide 
solution).  
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that a SNF admission is medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet the required criteria for a SNF admission. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is documentation that shows the enrollee requires the services on an inpatient 
basis in a skilled nursing facility setting. Provided records document a significant decline in the enrollees 
functional status compared to the recent baseline to necessitate daily inpatient skilled therapy 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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.