Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee currently requires assistance for all 
activities of daily living and transfers. You also say the enrollee is at a high risk for readmission to the hospital 
or a fall at home without IRF services. 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 do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that they would meet criteria for admission to an IRF. There is no indication that the enrollee 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain his functional status.  The 
member can receive further services at 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 pre-approve an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) and humidifier (E0526). 
 
You asked the Plan to pre-approve a CPAP device and humidifier. You say that the item is medically 
necessary. The Plan denied your request. The Plan says you had these items and returned them while they were 
still within their useful life and no evidence was presented that the device was not functional. 
 
The Plan must follow Medicare rules. Medicare rules say that the Reasonable Usable Lifetime (RUL) of the 
CPAP machine is 5 years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device and humidifier have not been met. Specifically, there is no indication the device you had was damaged beyond repair. Therefore, we decided that the Plan does not have to pre-approve a 
continuous positive airway pressure (CPAP) device (E0601) and humidifier (E0526).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dexcom G7 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve Dexcom G7. You say that you are appealing this denial. The Plan denied 
your request. The Plan says that the enrollee already has a Dexcom G6 sensor, so there is no justification for a 
Dexcom G7. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied authorization for this CGM on the basis that the enrollee 
already had a Dexcom G6 CGM that was meeting their needs. However, the Plan did not submit proof that the 
enrollee had already been furnished a Dexcom G6 which was currently in use at the time of your request. We 
requested this information from the Plan, but the Plan did not provide it to us. Without this information, we 
cannot determine whether the enrollees needs for a CGM were already being met at the time you made your 
request or whether any existing equipment the enrollee had was eligible for replacement according to Medicare 
rules. Therefore, the Plan has not shown that its decision to deny authorization for this device is correct or 
justified. Therefore, we decided that the Plan has to pre-approve a Dexcom G7 continuous glucose monitor 
(CGM).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee's entire L-spine is 
symptomatic, and the lower back pain is contributing to their lower back, sacral area, hip, and upper legs pain 
on both sides. The Plan denied your request. The Plan says radiofrequency ablation is 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 radiofrequency ablation. Our reviewer 
says that radiofrequency ablation is not medically necessary. Our physician reviewer found that the enrollee 
has lumbar spondylosis without myelopathy, radiculopathy, lumbosacral spondylosis, and low back pain. The 
enrollee has had a magnetic resonance imaging (MRI) of the lumbar spine which showed multilevel 
degenerative disc disease and facet arthropathy. The enrollee also has had left radiofrequency ablation at levels 
T12, L1, L2, L3, L4 and L5 with 80% pain relief on March 1, 2023, and March 26, 2023. Therefore, per the 
LCD coverage criteria the request is not 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve daily image guidance for radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this type of guidance is not needed or effective for the enrollee's skin 
cancer. 
 
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 requested services. Our physician 
reviewer found that image guided radiation therapy (IGRT) uses daily image guidance to help localize the 
target so as to minimize normal tissue dosing. When treating skin cancers, there is generally not a need for 
IGRT unless deep structures are being treated. Daily simple simulations and/or IGRT has not been established 
by published data or supported by consensus guidelines as necessary. Daily IGRT would not be furnished in 
accordance with accepted standards of medical practice 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve daily image guidance for radiation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that having an electric wheelchair will 
significantly improve the enrollee's quality of life and the ability to perform mobility related activities in the 
home safely. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
device. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a scooter. In addition, the documentation does not 
support that the enrollee has had a home evaluation that shows the enrollees home has space to accommodate 
the requested wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records support the need for 
the LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
admission to a long term acute care hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with basilar artery thrombosis and required endovascular 
intervention. 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 are not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 08, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are disputing the denied claims. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on December 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections. 
 
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 SI joint injections are covered when specific 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have bilateral 
SI joint pain and your physician recommended SI joint injections. The physical examination does not document 
three positive physical diagnostic signs. The criteria for coverage are not met and the SI joint injections are not 
reasonable or medically necessary at this time. 
 
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 sacroiliac (SI) joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823) and 
additional items and accessories (codes E0973 x2, E2365 x2, E1028, and K0108). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
You say that you need a powered wheelchair for outdoors to go shopping or wherever needed. You also say 
that you want a wheelchair that you can use outside that is sturdy and safe. The Plan denied your request. The 
Plan says Medicare does not approve power wheelchairs when their main or only purpose is movement while 
out of the home. The Plan also says while the desire for easy community mobility is understandable, Centers 
for Medicare & Medicaid Services (CMS) guidelines do not allow provision of a power mobility device mainly 
to allow use outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 standard power wheelchair (K0823) and additional items and accessories (codes 
E0973 x2, E2365 x2, E1028, and K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal adjustment (D9951). 
 
You asked the Plan to pre-approve an occlusal adjustment. You say that you do not understand why this service 
was denied. The Plan denied your request. The Plan says this periodontic service is not included in your benefit 
plan and therefore, is not a covered service. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal adjustment (D9951).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous laminectomy. 
 
You asked the Plan to pre-approve percutaneous laminectomy. You say that you are experiencing back pain 
and this procedure will reduce your back pain. The Plan denied your request. The Plan says the requested 
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 percutaneous laminectomy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found you have back pain. Percutaneous laminectomy is experimental. More research 
is needed to show safety and efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous laminectomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous laminectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-ray provided on August 01, 2022. 
 
You asked the Plan to pay for the office visit and x-ray. You say that the enrollee came in after a fall. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit and x-ray 
provided on August 01, 2022.
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 you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
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 reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. Provided records document that the home ventilator is being requested for use in intelligent 
volume assured pressure support (IVAPS) mode with auto-EPAP (AE) which could be provided by a bilevel 
positive airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a back-
up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
Ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and payment policy 
requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive airway 
pressure, regardless of the illness treated by the device. Claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and necessary. 
Therefore, the enrollee does not meet criteria for the requested device. 
 
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: 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 you are appealing this denial. The Plan denied your 
request. The Plan says that you do not meet criteria for SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit supporting medical records for review. We requested 
supporting records, but none were submitted. Without medical records, we cannot determine whether you meet 
criteria for SNF care. Therefore, the Plan has not shown that its decision to deny authorization for SNF care is 
correct or justified. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rhopressa. 
 
You asked the Plan to pre-approve Rhopressa. You say that the medication is needed to prevent irreversible 
vision loss. 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 Rhopressa.  
 
Benefits for Rhopressa 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 a continuous glucose monitor. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin or 
has a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.