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

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says Medicare guidance says the upgraded electronics (electronic connector) are 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a wheelchair accessory. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has had falls secondary to lower extremity weakness. She has 4-5/5 
strength in her upper extremities. Per Social Security Administration (SSA) 1862 (a)1(A), the requested 
accessory is not medically necessary as the enrollee has adequate strength to manage standard power drives. 
 
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 wheelchair accessory have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311).
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 If you were to go home, you would be at risk to fall 
if sent home. You state you have not even reached your baseline of therapy. The Plan denied your request. The 
Plan says that the skilled nursing facility (SNF) services requested do not meet the requirements for approval. 
 
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 the clinical documentation shows that the enrollee's past level of function was 
modified independent with mobility and needed some assistance with activities of daily living. Clinical 
documentation shows that the enrollee is currently requiring moderate assistance with transfers, balance and 
minimum assistance with grooming, maximum assistance with dressing (with unmet medical equipment and 
mobility goals) thus the enrollee continues to be significantly beneath functional baseline. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6740) for tooth #11. 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is medically necessary. 
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 D6740 was exhausted with the approved D6740 for tooth #8. Therefore, we decided that 
the Plan does not have to pre-approve a retainer crown (D6740) for tooth #11.
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 to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria.  
 
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. You were admitted for 
sepsis, COVID 19 infection, urinary tract infection and acute kidney injury. Medical problems are stable. There 
are no complex nursing or rehabilitation needs.  
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you 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 inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care from January 17, 2024, onward. You say that the 
requested care is a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested care is not medically necessary.  

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from January 
17, 2024, onward. Our reviewer says that inpatient psychiatric care from January 17, 2024, onward is not 
medically reasonable and necessary. Our physician reviewer found that the enrollee was admitted to acute 
inpatient psychiatric hospitalization on December 12, 2023, with Schizoaffective Disorder Bipolar Type. Based 
upon review of the records provided, it was not expected this enrollee would improve in a reasonable period of 
time for the dates in question, as the enrollee did not have suicidal or homicidal ideation nor auditory or visual 
hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from January 17, 2024, onward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clinical crown lengthening-hard tissue (D4249).  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not covered under the 
supplemental dental policy.  
 
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, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve clinical 
crown lengthening-hard tissue (D4249).
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 you are requesting an LTACH admission for the enrollee. 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 the enrollee does not require services at the LTACH that are not available at the acute care hospital. Given there are offered alternatives, an LTACH admission 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nonpneumatic compression devices (K1033, K1024). 
 
You asked the Plan to pre-approve nonpneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items are 
experimental/investigational. 
 
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 nonpneumatic compression devices. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the requested device is a nonpneumatic sequential compression garment 
with sequential calibrated gradient pressure that is used for the treatment of lymphedema. The requested device 
has not been shown to be superior to other standard treatments for the medical condition. The studies do not indicate the Koya Dayspring Active Compression Garment System improves an individuals function or 
general health compared to standard treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nonpneumatic compression devices have not been met. Therefore, we decided 
that the Plan does not have to pre-approve nonpneumatic compression devices (K1033, K1024).
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  recently had surgery and needs help learning 
how to walk again. The Plan denied your request. The Plan says you condition does not meet all the 
requirements for inpatient rehabilitation admission. The Plan says services may be provided at 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. It is not a 
reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with power tilt. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with power tilt. You say that the power tilt is 
medically necessary. The Plan denied your request. The Plan says there is not a medical need for the requested 
single power option. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered when 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 with 
power tilt. Our reviewer says that the requested Group 3 power wheelchair with power tilt is not medically 
necessary. Our physician reviewer found the documentation does not indicate that the enrollee has any pressure 
injuries or requires intermittent catheterization of the bladder or have spasticity that would necessitate power 
tilt or recline. Therefore, the reviewer found that the requested Group 3 power wheelchair with single power 
option 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 Group 3 power wheelchair with power tilt have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 power wheelchair with power tilt.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stryker Vitoss Synthetic Bioglass bone graft substitute. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Vitoss bioglass bone graft substitute 
is considered experimental in nature when used as a bone graft material. More research is needed to support its 
use. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Stryker Vitoss Synthetic Bioglass bone graft substitute.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a SPRINT PNS system. 
 
You asked the Plan to pre-approve the PNS. You say that a PNS implant is a viable solution to alleviate the 
enrollee's longstanding pain. The Plan denied your request. The Plan says that this procedure is not supported 
by research and is not covered. 
 
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 PNS. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that a PNS is evidence-based therapy for chronic stump pain. 
 
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 PNS have been met. Therefore, we decided that the Plan has to pre-approve 
a SPRINT PNS system.  
 
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 Group 3 power wheelchair with multiple power 
options (tilt/recline, legrests, seat elevator), and accessories.  
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that 
Medicare has reviewed and approved this request. The Plan denied your request. The Plan says there is not a 
medical need for the requested power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when 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 with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the documentation does not indicate that the 
enrollee has any pressure injuries or requires intermittent catheterization of the bladder or have spasticity that 
would necessitate power tilt or recline. Therefore, the reviewer found that the requested Group 3 power 
wheelchair with multiple power options 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 Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, legrests, seat elevator), and accessories.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve diagnostic exam of the esophagus, stomach and/or upper small 
bowel using a flexible endoscope (43235). 
 
You asked the Plan to pre-approve diagnostic exam of the esophagus. You say that this diagnostic service is 
necessary for the enrollee's anemia and blood loss. The Plan denied your request. The Plan says that this 
service is 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 diagnostic exam of the esophagus. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a diagnosis of iron deficiency anemia, so a diagnostic exam of 
the esophagus, stomach and/or upper small bowel using a flexible endoscope is medically necessary and 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic exam of the esophagus have been met. Therefore, we decided that 
the Plan has to pre-approve diagnostic exam of the esophagus, stomach and/or upper small bowel using a 
flexible endoscope (43235).  
 
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.