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

 
We decided that the Plan does not have to pre-approve wheelchair repairs. 
 
You asked the Plan to pre-approve wheelchair repairs. You say that this is not the enrollee's back up chair. You 
say that the enrollee was approved for a new wheelchair in 2022. You say that they decided not to get that 
chair. You also say that this needs to be approved. The Plan denied your request. The Plan says the total cost of 
repairs exceeds the cost of replacement. 
 
The Plan follows Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. 
 
We looked at the file, and Medicare rules. The record shows that the current requested repair costs show to be 
$866.45, and previous payments made for repair to this item show to have been $6,047.13. The total cost for 
replacement of this equipment is $3,326.36. This means that the expense for repairs to this item exceed the estimated expense of purchasing another item for the remaining period of medical need, and no payment can be 
made for the repair costs requested. Therefore, we decided that the Plan does not have to pre-approve 
wheelchair repairs.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (ferumoxytol) injection (Q0138). 
 You asked the Plan to pre-approve Feraheme. You say that this medication is medically necessity for the 
enrollee's treatment for iron deficiency anemia. The Plan denied your request. The Plan says the member has 
not tried and failed the preferred step therapy drugs Infed and Venofer. The Plan also says there is no indication 
our preferred drugs would likely be less effective, and/or cause adverse effects for the member. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that the 
enrollee does not meet the criteria for Feraheme (ferumoxytol) injection (Q0138). Our physician reviewer 
found the case file does not contain documentation of trial and failure of Infed and Venofer. Our physician 
reviewer also found that the available clinical documentation does not support that Infed and Venofer would 
likely be less effective, and/or would likely have adverse effects for the enrollee in this case. The record shows 
that a trial of both drugs mentioned is required before the drug at issue can be considered or approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (ferumoxytol) injection (Q0138).
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 this 
should be approved so the enrollee can have the appropriate medical equipment to meet their needs. The Plan 
denied your request. The Plan says the enrollee does not have a medical need for multiple power options 
included with the requested Group 3 power wheelchair. 
 
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 provided documentation does not support 
that the enrollee has a high risk for skin breakdown, uses a catheter intermittently, has spasticity or requires an 
alternative means of managing power drive. Therefore, the reviewer found that the requested Group 3 power 
wheelchair with multiple power options 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to an 
LTACH. The review has determined that the enrollee does not require services at the LTACH that are not 
available at the acute care hospital where they are currently receiving care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep study (G0399). 
 
You asked the Plan to pre-approve a home sleep study. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no documentation to show the enrollee has any symptoms/finding to 
support a home sleep study. 
 
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 home sleep study. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient has no features or symptoms related to obstructive sleep apnea and her 
pretest probability is low. The documentation provided does not support a home sleep study. 
 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 sleep study have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home sleep study (G0399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 12, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from December 12, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were 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 
December 12, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of December 12, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond December 12, 
2023, as she was not a danger to herself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
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 December 12, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 12, 
2023, forward.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vabysmo. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has age related exudative macular degeneration. The documentation does not support that 
the enrollee has tried and failed bevacizumab (avastin). The documentation does not support that bevacizumab 
(avastin) would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has suffered from chronic sacroiliac 
joint pain due to sacroiliitis for more than two years. The Plan denied your request. The Plan says that a 
sacroiliac joint injection 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 the injection. Our reviewer says that a 
sacroiliac joint injection is medically necessary. Our physician reviewer found that the request meets all of the 
LCD coverage criteria and is 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 the injection have been met. Therefore, we decided that the Plan has to pre-
approve a sacroiliac joint injection.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to an 
LTACH. The review has determined that the enrollee does not require services at the LTACH that are not 
available at the acute care hospital where they are currently receiving care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you need SNF services. The Plan denied your 
request. The Plan says you do not meet the requirements for an SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve mandibular partial denture. You say that this is medically necessary. The 
Plan denied your request. The Plan says the documentation submitted did not show the required missing teeth. 
 
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 mandibular 
partial denture 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 mandibular partial denture. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found tooth #31 is missing in 
the lower jaw. All other teeth except for the lower wisdom teeth (#17 and #22) are present in the lower jaw. There was no narrative included in the review of why the partial denture was recommended, or if there are 
teeth in the lower jaw that are planned for extraction. There is no documentation about which teeth in the 
mouth the denture is to replace. There are other options that an replace a single missing tooth. More 
information is required to determine whether the partial denture is medically necessary.  
 
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 mandibular partial denture have not been met. Therefore, we decided that the 
Plan does not have to pre-approve mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 2 power wheelchair (K0820). 
 
You asked the Plan to pre-approve a Group 2 power wheelchair. You say that you were provided with a manual 
wheelchair. You say that it is hard to move around with this. You say that you are afraid you will fall while 
using your walker. You also say that you are heavy and have no strength in your legs. The Plan denied your 
request. The Plan says that you should be checked to see that you can safely use this equipment. The Plan also 
says that the notes do not show that a power wheelchair is appropriate. 
 
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. We find that the Plan did not provide the medical records that were used to make 
their decision. We requested the records, but none were provided. Without this documentation we cannot 
determine if the Plan was correct in denying the requested power wheelchair. Therefore, we decided that the 
Plan has to pre-approve a Group 2 power wheelchair (K0820).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary. The Plan denied your request. 
The Plan says IRF care 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 enrollee's 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. The enrollee requires 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 the enrollee 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 you need IRF services in order to gain back 
maximum relative functioning of your body. The Plan denied your request. The Plan says you do not meet the 
requirements for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to 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. 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. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation program provided in an 
IRF. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.