Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omnipod 5 G6 pods. 
 
You asked the Plan to pre-approve Omnipod 5 G6 pods. 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 Omnipod 5 G6 pods. Benefits for Omnipod 5 G6 pods 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next diabetic test strips. 
 
You asked the Plan to pre-approve diabetic supplies. You say that this is medically necessary. The Plan denied 
your request. The Plan says the Plan requires use of preferred brand diabetic testing supplies which include 
Roche and Trividia products. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain brands. The 
enrollees contract with the Plan says that the Plans only covered brands are ACCU-CHEK manufactured by 
Roche or Trividia products. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve Contour Next diabetic test strips.
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 services are medically necessary. The Plan 
denied your request. The Plan says that you are receiving appropriate inpatient acute care and are currently 
unstable for transfer to an LTACH.  
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that BiPAP devices are limited. The Plan denied your 
request. The Plan says a BiPAP has not been ruled out.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 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 ventilator. Our physician reviewer 
found that the enrollee has severe COPD and has had a home ventilator since February 21, 2023. On April 28 
approval was extended 90 days to allow the enrollee time to obtain BiPAP. Compliance with the current device 
was recently assessed. The enrollee is using the device at least 4 hours/day for 83% of days. There is no arterial 
blood gas documenting chronic carbon dioxide retention. If that is present, the enrollee would benefit from 
BiPAP during sleep.  Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. Therefore, the request 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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 services are medical necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare 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 the enrollee does not require treatment by multiple therapies. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a high frequency chest wall oscillation device (HFCWOD) 
provided November 11, 2022, to January 11, 2023. 
 You asked the Plan to pay for  a HFCWOD. You say that please find the medical record supporting medical 
necessity and overturn the denial on these claims. The Plan denied your request. The Plan says the records do 
not support that the medically necessary criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a high-frequency chest wall oscillation device is not medically necessary. This enrollee has 
COPD with a chronic cough and sputum production. There is no diagnosis of bronchiectasis, cystic fibrosis, or 
neuromuscular disease. There is inadequate evidence that this device is beneficial in the treatment of COPD, 
and Medicare does not cover it for that diagnosis.   
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pay for  a high frequency chest wall oscillation device (HFCWOD) provided November 11, 2022, to 
January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the removal of residual tooth roots (cutting procedure) tooth #18 
(D7250). 
 
You asked the Plan to pre-approve the removal of residual tooth roots for tooth #18. The Plan denied your 
request. The Plan says that the documentation did not meet the clinical criteria for the removal of residual tooth 
roots (cutting procedure) tooth #18 (D7250). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the removal 
of residual tooth roots for tooth #18 when the services are medically necessary and reasonable. 
 
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 removal of residual tooth roots for 
tooth #18. Our reviewer says that criteria for coverage for D7250 is medically necessary. Our physician 
reviewer found the documentation indicates the presence of residual roots of tooth #18. These roots appear to 
have 50% bone surrounding each. It is medically reasonable and necessary that a cutting procedure is required 
to remove tissue and bone to facilitate their removal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the removal of residual tooth roots for tooth #18 have been met. Therefore, we 
decided that the Plan has to pre-approve the removal of residual tooth roots (cutting procedure) tooth #18 
(D7250).  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the clinical summary and clinical documentation 
support this request. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for rib fractures, pancreatitis and rhabdomyolysis after a fall. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. While the medical records support 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires inpatient rehabilitation services 
for management of complex, potentially life endangering medical comorbidities. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical management of a perforated colon. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support 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 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 services are medically necessary for the 
enrollee's care. The Plan denied your request. The Plan says the enrollee does not appear to be medically stable 
to safely participate in the intensive therapy requested for their brain injury and seizures.  
 
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. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug test,15-21 drug classes (G0482) and 
presumptive drug class screening (80307) provided October 28, 2022. 
 You asked the Plan to pay for the laboratory service. You say that please review attachments diagnosis code 
Z79.891 supports medical necessity. The Plan denied your request. The Plan says the testing does not meet the 
Medicare criteria. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
reviewer found the enrollee with chronic pain and anxiety, treated with morphine, Hysingla ER, Oxycodone, 
Fentanyl, Naloxone, Gabapentin, Duloxetine, Baclofen, and Celecoxib. Definitive drug test,15-21 drug 
class(es), including metabolite(s) if performed (G0482) presumptive drug class screening (80307) was 
requested. However, the provided records did not show a basic urine drug screen test (point of care) resulting in 
unexpected results to warrant a comprehensive definitive testing follow-up. There was no report of illicit drug 
use, signs or symptoms of such. There was also insufficient evidence to support testing for more than 5 drug 
classes. Therefore, the definitive drug test, 15-21 drug classes will be considered not medically necessary.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive drug test,15-21 drug classes (G0482) and presumptive drug class screening 
(80307) provided October 28, 2022.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show that you have complex 
rehabilitation needs that require frequent evaluation by a rehabilitation doctor. Services needed may be 
provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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. 
 
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 high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that kindly see the attached documentation and 
reconsider this decision to deny coverage. The Plan denied your request. The Plan says with no clinical 
information, unknown if chronic cough or antibiotic therapy, requested device not reasonable or medically 
necessary.  
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a high-frequency chest wall oscillation device is not medically necessary. This enrollee has a 
diagnosis of bronchiectasis as well as interstitial lung disease. Notes from the visit of March 23, 2023, indicate 
increased productive cough. However, the medical records do not include a chest computed tomography (CT) 
scan report documenting bronchiectasis. There is no evidence in the record that the enrollee has tried and failed 
other traditional methods of airways clearance, such as a flutter valve and there is no evidence of a 
bronchiectasis exacerbation. The denial is upheld. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested item is a 
medical necessity for you. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service.  
 
 
  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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism, regardless of how they are billed on the 
claim. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Kit sensor.  
You asked the Plan to pre-approve the FreeStyle Kit sensor. You say that the enrollee has dementia and cannot 
check glucose. The Plan denied your request. The Plan says no hypoglycemia is reported in chart notes. 
 
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 pre-approve the FreeStyle Kit sensor. Our reviewer 
says that the FreeStyle Kit sensor is not medically necessary. Our physician reviewer found Metformin is not a 
medication that causes low blood glucose sugar, and if the A1C is high suggesting the need for another 
medication, then this needs to be prescribed regardless of what the libre shows. The criteria for the libre 
coverage are not met and there is not a convincing argument for the need for or utility of a libre in this enrollee 
on Metformin. 
 
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 FreeStyle Kit sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle Kit sensor.