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

 
We decided that the Plan does not have to pre-approve a replacement semi-electric hospital bed. 
 
You asked the Plan to pre-approve a replacement hospital bed. You say that the enrollees current bed is falling 
apart. You also say that they need a new bed. The Plan denied your request. The Plan says a replacement bed is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a replacement hospital bed have not been met. Specifically, the file supports that the enrollee's 
current bed was received in 2022. Additionally, the record does not support that the current bed has irreparable 
damage. Therefore, we decided that the Plan does not have to pre-approve a replacement semi-electric hospital 
bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an enteral nutrition product (B4153). 
 
You asked the Plan to pre-approve an enteral nutrition product . You say that you need this to increase your 
strength prior to surgery. The Plan denied your request. The Plan says you do not have any permanent 
gastrointestinal dysfunction. 
 The Plan must follow Medicare rules. Medicare rules say that enteral nutrition for temporary impairments will 
be denied as non-covered, no benefit. 
 
We looked at the file and Medicare rules. In this case your medical records do not show that you have a 
permanent impairment of the gastrointestinal tract. Based on this information, we decided that Medicare rules 
for coverage of an enteral nutrition product  have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an enteral nutrition product (B4153).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein 
(36478). 
 
You asked the Plan to pre-approve endovenous ablation therapy of incompetent vein. 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 follows Medicare rules. Medicare rules say that surgical treatment of varicose veins of the lower 
extremities are covered under certain circumstances. 
 
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 endovenous ablation therapy of 
incompetent vein. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the documentation does not meet coverage criteria and does not support the medical necessity of the 
treatments in question. The enrollee has left leg pain and ulceration despite numerous vein ablations and 
perforator sclerotherapy. It is not possible to attribute the enrollees symptoms to any residual varicosities 
without an assessment of arterial perfusion of the lower extremities, particularly in a enrollee with multiple risk 
factors for peripheral artery disease including a history of peripheral artery disease. There is no evidence of an 
assessment of arterial perfusion to the lower extremities in the documents provided. Coverage criteria require 
the absence of significant peripheral artery disease. Additionally, the appropriateness/medical necessity of the 
treatments in question cannot be supported with the current documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy of incompetent vein have not been met. Therefore, 
we decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein 
(36478).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on December 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim did not 
include the required dual diagnosis ICD-10-CM code. 
 
The Plan must follow Medicare rules. Medicare rules say that A57674 provides a list of appropriate dual 
diagnosis "Z" codes.  
 
We looked at the file and Medicare rules. The claim in question was billed with code Z99.2, which is not listed 
as an appropriate dual diagnosis "Z" code, per LCA A57674. 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 the ambulance services provided on December 8, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services with a Doctor of 
Philosophy (PhD). 
 
You asked the Plan to pre-approve the outpatient mental health services. You say that this therapy has been 
recommended to you.  You have been seeing this provider for several years and you are still having a tough 
time coping.  You said that you do not want to start over with a new therapist. The Plan denied your request. 
The Plan says the provider you want to see is not a Medicare-eligible provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  
 
The provider you are requesting to see is not one of the above-listed provider types eligible to provide services 
to Medicare patients.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve outpatient mental health services with a Doctor of Philosophy (PhD).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service September 
18, 2022.  
 
You asked the Plan to pay for procedure code 99285. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99285 is bundled into payment for code 99220. 
 
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, we have confirmed that code 99285 
is a column II code to column I code 99220 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we decided that 
the Plan does not have to pay for procedure code 99285 billed for date of service September 18, 2022.
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 IRF services requested do not meet the requirements for approval. 
 
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 treatment by multiple therapies or an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits at an in-network benefit level to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits at an in-network benefit level to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits at an in-network benefit level to be provided by an out-of-network (OON) provider.
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 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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have a diagnosis of chronic respiratory failure due to chronic obstructive pulmonary disease (COPD). The records do 
not show that you have tried and failed using a bi-level positive airway pressure (BiPAP) device. The criteria 
for coverage are not met and the home ventilator is 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 a home ventilator.
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 member does not meet all 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 enrollee does not require treatment by multiple therapies or an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient lift, hydraulic or mechanical (E0630). 
 You asked the Plan to pre-approve a patient lift. You say that you are unable to stand up without falling due to 
a stroke. Your spouse is unable to lift you or help get you into bed. The Plan denied your request. The Plan says 
there is no physician order for the requested lift. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Medicare rules say that an order for each item 
must be signed and dated by the treating physician. The record also shows that the enrollees physician will not 
order a lift until the enrollee is evaluated. Therefore, we decided that the Plan does not have to pre-approve a 
patient lift, hydraulic or mechanical (E0630).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on December 29, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered chiropractic services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine.  Therefore, we decided that 
the Plan does not have to pay for the chiropractic services provided on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with the requested tertiary provider.  
 
You asked the Plan to pre-approve the outpatient services. You say that you have been under this doctors care 
since January 2020. You say that it is life or death for you to return to this provider as you require medication 
for your severe condition. The Plan denied your request. The Plan says there are network providers available to 
provide the requested follow-up care. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 outpatient services. Our reviewer 
says that the requested outpatient service with the requested tertiary provider is not medically necessary. Our 
physician reviewer found the provided documentation indicates the enrollee could receive the same ongoing 
care (medication management) from an in-network provider. Their condition is otherwise described as being 
controlled at this time. The reviewer found that the plan has demonstrated network sufficiency in a geographic 
area relative to you. Therefore, the reviewer found that the requested services with the tertiary provider are not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve office visits with the requested tertiary provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve footrest, lower extension tube replacements (K0043 x2), 
swingaway detachable footrests (K0052), and transit kit (K0108). 
 
You asked the Plan to pre-approve a footrest, lower extension tube replacements, swingaway detachable 
footrests, and transit kit. The Plan denied your request. The Plan says the transit kit does not serve a medical 
need and cannot be covered. The so says that payment of detachable footrests and footrest lower extension 
tubes, is included in the requested code for the group 3 power wheelchair. 
 
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. Medicare rules also say that a Column II code is included in the allowance 
for the corresponding Column I code when provided at the same time. 
 The transit kit (K0108) 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. The record shows that you were approved 
for coverage of a group 3 standard power wheelchair (K0856), and footrest, lower extension tube replacement 
(K0043) and swingaway detachable footrests (K0052) are included in the allowance for code K0856. 
Therefore, we decided that the Plan does not have to pre-approve footrest, lower extension tube replacements 
(K0043 x2), swingaway detachable footrests (K0052), and transit kit (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee's partial denture was lost and a 
replacement is needed. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 21, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a lower partial denture (D5212).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you can't transfer by yourself and you are a major 
fall risk. The Plan denied your request. The Plan says based on Medicare guidelines and the information we 
have about your condition you don't meet all of the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
knee replacement surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
While the medical records support a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 it is medically necessary. The Plan denied your 
request. The Plan says that you do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines.   
 
Our physician reviewer found based on the documentation provided, you qualify for SNF coverage. You have 
documented skilled nursing needs. You require multiple forms of wound care, as often as daily, to multiple 
wounds. You do not have documented skilled therapy needs. You appear to be functioning at/near your 
baseline.  Daily skilled services are required to establish a maintenance program or to prevent deterioration of 
your 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as you no longer need the service and proper notice has been issued, or the 100-day 
Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility 
(SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.