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

We decided that the Plan does not have to pre-approve an air filter. 
 
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 covered. 
 
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 an air filter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they 
are medically reasonable and necessary and replace a blood glucose monitor.  
 
We looked at the file and Medicare rules. Medicare rules also say that therapeutic CGMs are covered only 
when a patient has been performing four or more blood glucose testing's every day and is insulin-treated with 
at least three or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin 
infusion (CSII) pump. The file shows that you do not test your blood glucose levels at least four or more times 
a day and you are neither insulin-treated nor have a CSII pump. Based on this information, we decided that 
Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection, anesthetic agent; other peripheral nerve or 
branch, innervating the sacroiliac joint, with image guidance. 
 
You asked the Plan to pre-approve nerve block (64451). You say that the enrollee needs the service for pain 
management. The Plan denied your request. The Plan says the requested procedure is experimental and 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 nerve block (64451). Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that a sacral lateral branch block is medically reasonable 
and necessary for the enrollee in this case. The effectiveness of such a block has not been sufficiently 
demonstrated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nerve block (64451) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an injection, anesthetic agent; other peripheral nerve or branch, innervating the 
sacroiliac joint, with image guidance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee on December 
31, 2019. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no authorization for these services. 
 
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 has network providers 
available who can provide 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 home health services provided to the enrollee on 
December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant supported crown and custom-fabricated 
abutment. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered benfeit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested codes - D6066 and 
D6057 - are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve an implant supported crown and custom-fabricated abutment.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex spacer. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has complaints of moderate 
to severe low back pain radiating into the bilateral lower extremity in a non-dermatomal pattern, and numbness 
and tingling over the bilateral anterolateral thighs. The Vertiflex spacer is not the standard of care and is not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair van transportation. 
 
You asked the Plan to pre-approve wheelchair van transportation. You say that the enrollee needs a wheelchair 
van to get to the doctor. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair van transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the denial of authorization for this item is 
correct, because this item is not covered by Medicare under the circumstances. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics and power seat elevation 
feature. 
 
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller 
harness (E2313), and Expandable controller (E2377), and power seat elevation feature (E2300). You say that 
the enrollee needs a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says 
the seat lift does not serve a primary medical purpose and the notes do not show a medical need to control the 
power options through the joystick. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose and/or be medically necessary.   
 
The power seat elevation feature does not serve a purpose that is primarily medical in nature. This item is not 
covered by Medicare. The record shows upper limb strength and range of motion are adequate for the enrollee 
to be able to control the power options using their own switches which are included in the allowance of these 
power options. Therefore, we decided that the Plan does not have to pre-approve the upgraded electronics and 
power seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve power wheelchair battery. You say that the batteries are a needed part of the 
wheelchair. The Plan denied your request. The Plan says the denial of authorization for this item is correct, 
because this provider is out-of-network with the Plan and this item can be obtained from an in-network 
supplier. The Plan also says that your wheelchair should be evaluated first to see if a new wheelchair is more 
appropriate than a new battery. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI scan of the abdomen. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no clinical documentation provided to show abnormalities on the 
ultrasound, symptoms, or other imaging procedures. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found you have a history 
thought to reflect non-alcohol steatosis hepatitis. As such, the risk of underlying primary hepatocellular 
carcinoma (HCC) is elevated. The ultrasound revealed a dense fatty liver. This technique is not optimal for 
liver evaluation for masses when the parenchyma is dense. Further detailed viewing of the liver is warranted, 
and MRI would be the procedure of choice. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
MRI scan of the abdomen.  
 
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 MyoCycle Home FES cycling therapy system 
(E1399). 
 
You asked the Plan to pre-approve the MyoCycle system. You say that the system is medically necessary. The 
Plan denied your request. The Plan says the system does not meet coverage criteria, and additionally the 
supplier is not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that suppliers must enroll in the Medicare program to 
be eligible to receive Medicare payment. The rules also state that coverage for the use of FES is limited to 
spinal cord injury patients for walking. 
 
We looked at the file and Medicare rules. The provider in this case is not enrolled in the Medicare program and 
is therefore ineligible for payment. Additionally, the device requested is a cycling device and does not aid the 
enrollee in walking. Based on this information, we decided that Medicare rules for coverage of the MyoCycle 
system have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoCycle 
Home FES cycling therapy system (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair seat elevation system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered item. 
 
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 power wheelchair seat elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sphygmomanometer/blood pressure monitor with cuff 
and stethoscope (A4660). 
 
You asked the Plan to pre-approve the item. You say that this is needed to keep track of your vitals. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a sphygmomanometer/blood pressure monitor 
with cuff and stethoscope (A4660).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair fan transportation. 
 
You asked the Plan to pre-approve wheelchair fan transportation. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair fan transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA) and medial 
branch block (MBB) injections. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have chronic low back pain and have had physical therapy and medication trials. You have had two diagnostic 
MBBs, followed by lumbar spine RFA. You achieved 60 percent pain relief for three weeks after the RFA. As 
the pain relief from the RFA did not last six months, RFA is considered failed and should not be repeated. The 
requested services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar radiofrequency ablation (RFA) and medial branch block (MBB) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a second 
opinion. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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 
a referral to an out-of-network provider for a second opinion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ultra-lightweight manual wheelchair (K0005) and 
accessories (E0973, E2611, E0961). 
 
You asked the Plan to pre-approve a ultra-lightweight manual wheelchair and accessories. You say that the 
medical records provided should support the necessity of the services in dispute. The Plan denied your request. 
The Plan says the records do not support the necessary criteria. 
 
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 ultra-lightweight manual wheelchair 
and accessories. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation does not indicate that the enrollee 
requires individualized fitting and adjustments for one or more features such as, but not limited to, axle 
configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001 through 
K0004 manual 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 a ultra-lightweight manual wheelchair and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a ultra-lightweight manual wheelchair 
(K0005) and accessories (E0973, E2611, E0961).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapy 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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 
a referral to an out-of-network physical therapy provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is only covered when part of a clinical 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the MILD procedure is experimental. More research is needed to show the safety and efficacy of the 
procedure. It should not be 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous image-guided lumbar decompression for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the services. You say that this should be covered. The Plan denied your 
request. The Plan says the benefits have been exhausted. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that with this request, you will have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.