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

 
We decided that the Plan has 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 appealing the denial. The Plan denied your 
request. The Plan says the enrollee lacks medical complexity, and needs can be met in a lower level of care. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the complexity of the enrollees nursing medical and rehabilitation needs does require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was hospitalized 
after falling down a flight of stairs and suffering multiple fractures, and required open reduction and internal 
fixation of radius fractures. The enrollee is noted to have respiratory failure and require supplemental oxygen at 
baseline. The enrollee would benefit from the oversight of a rehabilitation physician and nursing care, given the 
polyorthotrauma and respiratory issues. The enrollee's medical and rehabilitation needs do require the intensive 
interdisciplinary approach provided in acute inpatient rehabilitation. The enrollee does require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program at least three hours a day and five days a week, or 15 hours over seven consecutive days. The 
enrollee is currently non-weight bearing in the upper extremities. The enrollee requires maximum assistance for 
daily activities, including dressing, toileting, and bathing, minimal assistance for transfers mobility and 
transfers, and moderate assistance for bed mobility. The enrollee has had a significant decline in level of 
function and would benefit from the intensity of therapies provided in acute inpatient rehabilitation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi 
 
You asked the Plan to pre-approve Leqembi. The Plan denied your request. The Plan says the requested drug is 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Leqembi. Our physician reviewer found 
that the enrollee has a diagnosis of Alzheimer's disease. Leqembi is FDA approved for the treatment of mild 
cognitive impairment or mild stage Alzheimer's dementia. The provided records in this case document a 
diagnosis of Alzheimer's dementia, unspecified and "a progressive dementia." The enrollees documented 
cognitive testing does not clarify that the enrollee is in the mild stages of the disease.  The use of Leqembi for unspecified dementia (not clearly mild stage) is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The requested use of 
Leqembi does not meet Medicare criteria for safe and effective and otherwise reasonable and necessary for the 
enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that a 
power wheelchair with tilt and recline are required for the enrollee's condition. The Plan denied your request. 
The Plan says that although there are three approved power options on this wheelchair (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee is functionally non-ambulatory and 
requires a power wheelchair for mobility and performing daily activities. They cannot perform pressure relief 
independently due to upper extremity weakness and require a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. There is a history of skin breakdown. Power elevating leg rests are 
required for positioning of the lower extremities and lower extremity edema. Our reviewer found that the 
complexity of the enrollees seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. The expandable controller with harness and electronic connection are necessary to operate the 
group 3 power wheelchair base and the three power options via a joystick. Our physician reviewer also found 
that these components are required to operate 3 or more power options on a group 3 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig (E1399). 
 
You asked the Plan to pre-approve a wig. You say that you need this item. The Plan denied your request. The 
Plan says this is not a covered item. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (CardioMEMS). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says the CardioMEMS device is considered unproven and 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 CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management.  Our physician reviewer found at this time, the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor (CardioMEMS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated knee orthosis (L1845) with sleeve 
(L2397). 
 
You asked the Plan to pre-approve prefab knee orthosis. You say that the enrollee risks further injury without 
this. The Plan denied your request. The Plan says the records do not indicate that bracing is part of the 
enrollee's treatment plan. 
 
The Plan follows Medicare rules. Medicare rules state that prefabricated knee orthoses may be covered for 
certain indications.  
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 prefab knee orthosis. Our reviewer says 
that the enrollee does not meet criteria for the requested knee orthosis. Our physician reviewer found the 
documentation does not reveal evidence of objective joint laxity or instability on a physical examination. There 
is no evidence of a recent injury or surgery to the right knee. The requested knee orthoses and the 
accompanying sleeve exceed the patient's medical needs are not medically 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 prefab knee orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a prefabricated knee orthosis (L1845) with sleeve (L2397).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis 9L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that this is medically necessary. The Plan 
denied your request. The Plan says the item is considered experimental. 
 
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 MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the item is considered experimental. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis 9L8702).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred drug.  
 
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 Eylea. Our physician reviewer found 
that Eylea was requested to treat age-related macular degeneration. The Plan requires a trial of bevacizumab 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. 
There is no documentation provided indicating that the Plan's required drug would likely be less effective 
and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopy, wrist, surgical, with release of transverse 
carpal ligament (29848). 
 
You asked the Plan to pre-approve endoscopy, wrist, surgical, with release of transverse carpal ligament. You 
say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that 
the enrollee has a diagnosis of carpal tunnel syndrome by either clinical signs and symptoms or that the 
enrollee has had electrodiagnostic testing of the median nerve in the absence of documented clinical signs and 
symptoms of carpal tunnel syndrome. 
 
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 endoscopy, wrist, surgical, with release 
of transverse carpal ligament. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found detailed documentation regarding a trial 
and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. 
Additionally, the provided clinical examination did not clearly corroborate carpal tunnel syndrome. Moreover, 
there are no electrodiagnostic studies showing pathology. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endoscopy, wrist, surgical, with release of transverse carpal ligament have not 
been met. Therefore, we decided that the Plan does not have to pre-approve endoscopy, wrist, surgical, with 
release of transverse carpal ligament (29848).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that a CGM will help you be healthier, and you do not 
understand why the Plan will not cover it. The Plan denied your request. The Plan says the Medicare criteria 
was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the CGM coverage criteria includes 
insulin use or low blood sugars. We are not told that the enrollee is being started on insulin, though with an 
A1c of 11.5 this might occur soon. If the enrollee is started on insulin, this information should be submitted and 
the case re-reviewed. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 12, 2023. 
 
You asked the Plan to pay for the home health services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this claim was submitted with the wrong Type 
of Bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that Type of Bill code is a 4-digit alphanumeric code 
that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim). 
 
 In this case, you billed with Type of Bill code 323, when you should have submitted type of bill code 329. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a roll-in shower. 
 
You asked the Plan to pre-approve a roll-in shower. You say that you need a roll-in shower in order to get 
cleaned daily.  You said that daily showers will help you to heal properly and to stay clean. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a roll-in shower.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you had knee replacement surgery, and it 
causes you a lot of pain to sit on a standard toilet seat. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), and detachable armrests (E0973 x2). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and detachable 
armrests. The Plan denied your request. The Plan says although there are three approved power options on this 
wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options 
through the joystick. The Plan also says that payment of armrests is included in the requested E1007 code for 
power tilt and recline, and a separate request for E0973 armrests should be denied as unbundled. 
 
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 an electronic connection, harness, 
expandable controller, and detachable armrests. 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 
cerebral palsy and is able to self-feed. Our reviewer also found that the enrollee has sufficient strength and 
function in their upper extremities to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, expandable controller, and detachable 
armrests have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), harness (E2313), expandable controller (E2377), and detachable armrests (E0973 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve wound care services. You say that the requested provider is closer to the 
enrollee and is the hospital the nursing home uses. The Plan denied your request. The Plan says their original 
decision to deny authorization was correct. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
 
  The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve wound care services to be provided by an out-of-network provider.