Persius/hicric huggingface dataset:
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 enrollee is getting weak due to getting a 
respiratory syncytial virus (RSV) and COVID-19. The Plan denied your request. The Plan says an IRF 
admission 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 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 he would meet criteria for admission to an acute inpatient rehabilitation facility. The 
enrollee 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 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies as an 
outpatient or at a skilled nursing facility may be approved upon request.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute 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 she would meet criteria for admission to an acute inpatient rehabilitation facility. The 
enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on November 8, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the PT services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the enrollee does not have OON benefits. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided on 
November 8, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87500, 87641, 87798, G0452, 87491, 
87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651, and 87653 provided on September 11, 
2023. 
 
You asked the Plan to pay for procedure codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 
87532, 87563, 87591, 87661, 87481, 87651, and 87653. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 
87532, 87563, 87591, 87661, 87481, 87651, and 87653 provided on September 11, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional 30 miles, a total of 80 miles per trip, routine 
transportation. 
 
You asked the Plan to pre-approve additional miles. The Plan denied your request. The Plan says you request 
has exceeded your benefit limit. 
 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 a maximum of 50 miles per trip trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional 30 miles, a total of 80 miles per trip, routine 
transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repair of wound of eyelids, nose, ears, or lips by 
transferring skin (14060), the reconstruction of the chin (21120), and the reconstruction of the nose (30420). 
 
You asked the Plan to pre-approve the surgery. You say that you are feeling discomfort, which is hurting you 
physically and mentally. The Plan denied your request. The Plan says the gender reassignment surgery 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 the surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records document your head and neck exam as "normal" and "normocephalic and 
atraumatic" with no documentation of an illness or injury or a congenital, acquired, traumatic or developmental 
anomaly or functional impairment or complications arising from cosmetic surgery such as infection, 
hemorrhage, or other serious documented medical complication to support necessity of the surgery. The 
provided records do not document your condition requires the prompt repair of an accidental injury or is 
required to improve the functioning of a malformed body member.  
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the repair of wound of eyelids, nose, ears, or lips by transferring skin (14060), the 
reconstruction of the chin (21120), and the reconstruction of the nose (30420).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of Vyzulta Sol 0.024%. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is stable on Vyzulta and needs to 
continue treatment (start date May 27, 2021). 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 the continued use of 
Vyzulta Sol 0.024%.  
 
Benefits for the medication 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 home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that the enrollee is under your care for 
management of her chronic respiratory failure (CRF) secondary to obesity hypoventilation syndrome (OHS). 
You also say that the enrollee was prescribed non-invasive ventilation after a life threatening COPD 
exacerbation, carbon dioxide (CO2) level was 60mmHg despite being treated with BiPAP therapy.   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 the home ventilator is not medically necessary. Our physician reviewer found the enrollee has severe 
obesity, obstructive sleep apnea noncompliant with CPAP, and obesity hypoventilation syndrome. Medical 
records indicate spirometry has shown restrictive lung disease. There is no diagnosis of COPD, thoracic 
restrictive disease, or neuromuscular disease. The enrollee was hospitalized in October 2023 with acute mental 
status changes and blood gases consistent with acute on chronic hypercarbic respiratory failure. The enrollee 
may benefit from BiPAP with a volume assurance mode during sleep as an outpatient if compliance can be 
achieved. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473), deep 
sedation/general anesthesia  first 15 minutes (D9222), and deep sedation/general anesthesia  each subsequent 
15-minute increment (D9223). 
 
You asked the Plan to pre-approve the dental services. You say that you are need of a lower partial dental, so 
you would like the surgery to be approved. The Plan denied your request. The Plan says the removal of torus 
mandibularis (D7473) is not covered under your Plan, therefore, the anesthesia has been denied also. 
 
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 anesthesia is not covered 
under this benefit as the removal of torus mandibularis is not a covered benefit. Therefore, we decided that the 
Plan does not have to pre-approve the removal of torus mandibularis (D7473), deep sedation/general anesthesia 
 first 15 minutes (D9222), and deep sedation/general anesthesia  each subsequent 15-minute increment 
(D9223).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing (81479) provided on 
October 18, 2022. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing (81479). You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Per review of the DEX Diagnostic Exchange, the GeneSight 
Psychotropic test was reviewed through the MolDX process and was found to not meet Medicare coverage 
criteria. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing 
(81479) provided on October 18, 2022.
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 options (K0861) and related accessories. 
 
You asked the Plan to pre-approve a power wheelchair and related accessories. You say that the requested 
items are medically necessary for the enrollee. The Plan denied your request. The Plan says the requested items 
are not medically necessary. 
 
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.  
 
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 power wheelchair and related 
accessories. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found the 
enrollee does not have high risk for skin breakdown, does not use a catheter intermittently, does not have 
spasticity, and does not require an alternative means of managing power drive. As the power wheelchair base is 
not medically necessary, 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 power wheelchair and related 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 
options (K0861) and related accessories.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the services the enrollee needs can be provided safely in other settings.  
 
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's medical complexity does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The enrollee does not require an intensive 
rehabilitation therapy, and it is unclear if they would tolerate it. There is not a reasonable expectation that the 
enrollee will be able to benefit from the intensive rehabilitation 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee continues to remain 
hypercapnic, which can lead to increased hospitalizations and worse life conditions that can lead to death. 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. Our reviewer 
says that this device is not medically necessary. Our physician reviewer found the enrollee exhibits chronic 
respiratory failure and has compensated hypercapnia with BIPAP therapy that has been tolerated. She has 
failed use of Life2000 and continues to tolerate and be compliant with BIPAP. There is no indication at this 
time for a home ventilator given data and documentation provided.   
 
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 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoe inserts (L3000).  
 
You asked the Plan to pre-approve foot orthotics. You say that you have horrible arthritis in your feet and 
ankles. You need a pair of foot inserts to alleviate the pain. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve shoe inserts (L3000).