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

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power option (K0861) and additional items and accessories (codes E0955, E1002, E1012, E1028, E2300, 
E2311, E2313, E2361, E2377, E2607, E2620, and K0108). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power 
options included with a K0861 group 3 power wheelchair. The Plan also says the electronic connection, 
harness, and expandable controller cannot be covered as it is not medically necessary to control the three 
requested power options through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
 
 
 
 
 
 
 
 
 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 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found although records report a history of stroke/transient ischemic attack, physician 
records in this case report that the enrollee's mobility deficit is due to a prior femur fracture and that the 
enrollee denies residual weakness or hemiplegia due to the stroke/transient ischemic attack. The provided 
records do not support that the enrollee is high risk for skin breakdown, has a history of pressure ulcer(s) or has 
had skin flap surgery. Our reviewer found that the records do not document the enrollee performs bladder self-
catheterization and is unable to transfer independently or that they have increased muscle tone or spasticity to 
meet criteria for the power tilt and/or recline and thus the multiple power option base. Our physician reviewer 
also found that as the requested wheelchair base does not meet Medicare coverage criteria, the requested 
accessories are not covered.  
 
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 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power option (K0861) and additional items and accessories (codes E0955, E1002, 
E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, E2620, and K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara secretion clearance system (E1399, A9999). 
 
You asked the Plan to pre-approve a Volara system. You say that the enrollee is in immediate need of this 
device. The Plan denied your request. The Plan says the Medicare guidance says there is no information that 
says the use of this device in the home can help the enrollee. 
 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 Volara system. 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 bronchiectasis and chronic obstructive pulmonary disease (COPD), with a 
recent hospitalization for pneumonia and bronchiectasis exacerbation. The enrollee is unable to tolerate vest 
therapy because of kyphoscoliosis. The Volara device has 3 components: Airway oscillation, positive end 
expiratory pressure, and nebulization. The device has not been studied enough to show benefit in the treatment 
of any chronic lung disease. There is inadequate evidence that this device is as, or more, effective than other 
devices in achieving airways clearance. Medicare does not cover use of the Volara in the outpatient 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 a Volara system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara secretion clearance system (E1399, A9999).
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 are ready for discharge, and the hospital has 
advised that you need more physical therapy. You also say that you would like to be admitted to an IRF. The 
Plan denied your request. The Plan says based on the available information, admission to an IRF is not 
reasonable and 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 the complexity of your nursing, medical and rehabilitation can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. Our reviewer also found that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided 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 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that based on the documentation provided, coverage 
criteria has not been met. The Plan denied your request. The Plan says the services are 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 the complexity of your nursing, medical and rehabilitation can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) 
(64625). 
 
You asked the Plan to pre-approve SI joint RFA. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 SI joint RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SI joint RFA is experimental. More research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) (64625).
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to reimburse the additional amount charged that exceeds the $1,484 deductible for 
an IRF stay. We decided that the Plan does not have to reimburse $1,484 of the deductible applied for an IRF 
stay.  
 
You asked the Plan to reimburse the deductible for an IRF stay provided on September 7, 2022. You say that 
you disagree with the cost share applied. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reimburse the additional amount charged that exceeds the $1,484 
deductible for an IRF stay.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). The 2022 EOC states the deductible is $1,484 for inpatient 
hospital services, but states the deductible is subject to change. The Plan failed to provide the 2022 deductible 
in clear, accurate terms. Therefore, we decided that the Plan has to reimburse the deductible for an IRF stay.  
 
We also decided that the Plan does not have to reimburse $1,484 of the deductible applied for an IRF 
stay. 
 
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 $1,484 
deductible for an inpatient hospital stay. Therefore, we decided that the Plan does not have to reimburse $1,484 
of the deductible applied for an IRF stay. 
 
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 pay for the panoramic radiographic image (D0330) provided on June 
7, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that you do not think you should 
have to pay for x-ray services rendered and you do not agree with the $375 responsibility. The Plan denied 
your request. The Plan says your benefit for the panoramic radiographic image 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 service was exhausted on date of service May 10, 2023. Therefore, we 
decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on June 7, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you have been trying to get transportation 
for five days. The Plan denied your request. The Plan says the requested service is covered under your plan, but 
the requested amount exceeds the limit listed by the Plan. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Procrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Procrit is not indicated for the treatment of 
anemia associated with the treatment of acute and chronic myelogenous leukemia's (CML, AML), or erythroid 
cancers. The review has determined that the requested use of Procrit is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on July 21, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billed code 99285 is not substantiated by the clinical documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the history and physical were 
appropriate. The physical was unremarkable. Blood pressure was 153/88. The vitals were otherwise stable. The 
workup revealed no abnormalities. No treatment was administered. The documentation did not sufficiently 
support a high level of medical decision-making to justify CPT 99285. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) rendered on July 21, 2023.
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says you do not meet the criteria for the LTACH admission. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. There are no services available at the LTACH that you require 
that are not available at the health care setting being offered by the health plan. The requested LTACH services 
are not medically necessary, reasonable, and appropriate for your diagnosis and condition. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) on tooth #3 and 4 and an interim 
crown (D2799) on tooth #3 and #4. 
 
You asked the Plan to pre-approve the crowns. You say that you are in severe pain and your teeth cannot be 
repaired. The Plan denied your request. The Plan says there is no clinical evidence to support a crown and an 
interim crown is included in the allowance of a permanent crown. 
 
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 crowns 
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 crowns. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided x-rays show heavily restored 
teeth #3 and presumably #4, though it appears there was an approved bridge from tooth #3-5 with a pontic 
noted for #4.  As individual teeth, #3 and #4 would need to show that the existing restorations were defective 
and required replacement with full coverage crowns. If a bridge was approved, then individual units would not 
be approved, as ide from the tooth number discrepancy. Provisional crowns are part of the crown process and 
are not allowed to be separately billed. If a provisional crown is requested, it can only be considered where 
there is additional work that needs to be completed prior to the completion of the crown. There is no indication 
that any additional work to allow the crowns to be placed would need to be done in any of the documentation.  
 
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 crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a crown (D2740) on tooth #3 and 4 and an interim crown (D2799) on tooth #3 and #4.
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 feel the enrollee is a good candidate for inpatient 
rehabilitation. You also say that the enrollee was totally independent before coming to the hospital, and you 
believe inpatient rehabilitation would be great for their long-term prognosis. The Plan denied your request. The 
Plan says based on the available information, admission to an IRF is not reasonable and 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 the enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  Our reviewer also found that the enrollees care needs can be met 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 acute inpatient rehabilitation facility (IRF) admission and services.