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

 
We decided that the Plan has to pre-approve the electrical connection between the wheelchair controller and 
two or more motors (E2311), expandable controller (E2377) and harness (E2313). 
 
You asked the Plan to pre-approve the electrical connection between the wheelchair controller and two or more 
motors, expandable controller and harness. You say that the items are medically necessary. The Plan denied 
your request. The Plan says that the items are not medically necessary. 
 
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 pre-approve the electrical connection between the 
wheelchair controller and two or more motors, expandable controller and harness. Our reviewer says that the 
items are medically necessary. Our physician reviewer found the enrollee is non-ambulatory and requires a 
power wheelchair for mobility and performing daily activities. They cannot perform pressure relief 
independently due to upper extremity weakness and require a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. There is a history of skin breakdown and flap surgeries. Power 
elevating leg rests are required for positioning of the lower extremities and lower extremity spasticity. The 
complexity of the patients seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. The expandable controller with harness and electronic connection are necessary to operate the 
group 3 power wheelchair base and the three power options via a joystick. These components are required to 
operate 3 or more power options on a group 3 power wheelchair. 
 
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 electrical connection between the wheelchair controller and two or more 
motors, expandable controller and harness have been met. Therefore, we decided that the Plan has to pre-
approve the electrical connection between the wheelchair controller and two or more motors (E2311), 
expandable controller (E2377) and harness (E2313).  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is appropriate and 
the only option for a safe discharge for the enrollee. You say that the enrollee is at a high risk for a poor 
outcome, including death if they are discharged to any other lower level of care. The Plan denied your request. 
The Plan says an LTACH admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that due to the enrollee's oxygen needs, it is not safe for transfer to an LTACH, and 
their needs are being met in their current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and 
services provided from APRIL 26, 2023, through MAY 04, 2023. 
 
You asked the Plan to pay for the IRF care. You say that the enrollee required an IRF admission. The Plan 
denied your request. The Plan says submitted documents fail to show that the enrollee's condition met 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 pay for the 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 enrollees nursing, medical, and rehabilitation needs were complex. However, 
they did not require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. 
The enrollee did not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There was not a reasonable expectation that the 
enrollee would be able to fully participate in and benefit from an intensive rehabilitation therapy program 
provided in an IRF. The enrollee's needs could have been met in 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 pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from APRIL 26, 
2023, through MAY 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic superficial brachytherapy/echo guidance 
radiotherapy. 
 
You asked the Plan to pre-approve the electronic superficial brachytherapy/echo guidance radiotherapy. You 
say that the service is medically necessary. The Plan denied your request. The Plan says this service is 
considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the electronic superficial 
brachytherapy/echo guidance radiotherapy. Our reviewer says that the requested /services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found this service is considered 
experimental.  
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 electronic superficial brachytherapy/echo guidance radiotherapy have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the electronic superficial 
brachytherapy/echo guidance radiotherapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 30, 2023. Therefore, 
we decided that the Plan does not have to pay for the dental services on May 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF is medically necessary. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower 
level of care such as 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 enrollee is currently requiring minimal to moderate assist for transfers and 
ambulating 100 feet with a rolled walker and minimal assist. This means that the complexity of the patient's 
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.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with altered mental status in the setting of acute on chronic respiratory failure secondary to 
pneumonia. 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. The elements of the coverage rules are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test and an 
outpatient surgery provided on June 5, 2023 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test and an outpatient surgery. You say 
that you disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient diagnostic tests and a $375 copayment for outpatient surgery/outpatient hospital 
facility.  You have been asked to pay a $40 copayment for an outpatient diagnostic test and a $375 copayment for an 
outpatient surgery. The total amount you are being asked to pay is $415 ($375 + $40 = $415). This item/service 
falls within the outpatient diagnostic tests and outpatient surgery/outpatient hospital facility benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an outpatient diagnostic test and an outpatient surgery 
provided on June 5, 2023
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 a SNF is appropriate for short term rehab. The Plan 
denied your request. The Plan says a SNF admission is not medically necessary.   
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Koya non-pneumatic compression device. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee has severe bilateral lower 
limb swelling. The Plan denied your request. The Plan says that there is insufficient evidence the device is 
effective to treat lymphedema. 
 
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 pre-approve the requested device. Our physician 
reviewer found that the enrollee has a diagnosis of primary lymphedema. The enrollee was evaluated for 
bilateral lower limb and feet swelling. The enrollee related pain from nails and calluses with ambulation. The 
skin was warm and dry. Severe edema of the lower limbs and feet was documented. It is noted that the enrollee 
had been using compression, exercise, and elevation for over 4 weeks without any change. The active non-
pneumatic compression garment system has been shown to be beneficial in the management of lymphedema. 
The available documentation supports that the active non-pneumatic compression garment system is medically 
reasonable and necessary for the enrollee in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested device have been met. Therefore, we decided that the Plan has to 
pre-approve a Koya non-pneumatic compression device.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system (E0466) and an oxygen 
regulator (E1399). 
 
  You asked the Plan to pre-approve a home ventilator system (E0466) and an oxygen regulator (E1399). You 
say that discontinuing the enrollee's current therapy could be detrimental to their health. The Plan denied your 
request. The Plan says a home ventilator is not medically necessary for this patient because their needs can be 
met with an alternative device such as a BiPAP device with average volume-assured pressure support 
(AVAPS).  
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system (E0466) and 
an oxygen regulator (E1399). Our reviewer says that a home ventilator system (E0466) and an oxygen 
regulator (E1399) is not medically necessary. Our physician reviewer found that the enrollee had been on a 
CPAP but was having difficulties with the device. Also, the enrollee was prescribed a home ventilator in 
February of 2022, which is being used in the AVAPS-AE mode with good compliance in February and March 
of 2023. Also the enrollee has no diagnosis of COPD, thoracic restrictive disease , or neuromuscular disease. 
Additionally, the enrollee appears to be benefiting from nocturnal support with the AVAPS-AE mode which 
can be provided with a BiPAP. Therefore, a home ventilator 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 home ventilator system (E0466) and an oxygen regulator (E1399) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator system (E0466) 
and an oxygen regulator (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve promethazine. 
 
You asked the Plan to pre-approve promethazine. You say that the enrollee gets severe vertigo which causes 
nausea with the dizziness. You say that the medication has helped the enrollee function better when they get 
flare ups. The Plan denied your request. The Plan says that self-administered drugs do not fall under Medicare 
Part B coverage. 
 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 promethazine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that the medical records provided support the 
need for the requested home ventilator. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary for the enrollee because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS).  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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator. Our reviewer says 
that this item is not medically necessary. Our physician reviewer found the enrollee has been utilizing a Trilogy 
ventilator and to withdraw or change the delivery method is substandard care. Continued home ventilator is 
best practice. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home 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 you would benefit from this care. The Plan denied 
your request. The Plan says your medical condition does not require IRF services, and care can be safely 
provided in 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 your 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.