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

 
We decided that the Plan does not have to pre-approve a larger battery or a hip bag for your portable oxygen 
concentrator. 
 
You asked the Plan to pre-approve a larger battery or a hip bag. You say that you need a larger battery and a 
hip belt so you can get out easily without having to carry a heavy concentrator. The Plan denied your request. 
The Plan says the portable oxygen concentrator came with a travel bag and integrated battery. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
We looked at the file and Medicare rules. Equipment that is presumptively non-medical in nature and used 
primarily and customarily for a non-medical purpose, even though the item may have some remote medically-
related use, is not considered DME. Medicare will not pay separately or make any additional payment for 
backup equipment. There is no evidence your current equipment is not meeting your in-home needs. Based on 
this information, we decided that Medicare rules for coverage of a larger battery and hip bag have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a larger battery or a hip bag for your 
portable oxygen concentrator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional physical therapy. You say that the member has demonstrated 
moderate gains and requires additional treatment. The Plan denied your request. The Plan says the additional 
visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional physical therapy. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the specialized skill, knowledge and judgment of a 
qualified therapist are not required to establish, design and/or deliver a program to maintain the member's 
current condition or to prevent or slow further deterioration. 
 
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 additional physical therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have ankle pain and your doctor 
recommends you wear arch supports. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the lower partial denture. 
 
You asked the Plan to pre-approve the lower partial denture. You say that you should be able to use your 
prosthodontics benefit. The Plan denied your request. The Plan says that the service is not a covered benefit. 
 
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. The Plan covers prosthodontic 
services, which include dentures, partials and bridges once every five calendar years. 
 
We looked at the case file, Evidence of Coverage and Medicare rules. Based on this information, we decided 
that the Plan's rules for coverage of the lower partial denture have been met. The Evidence of Coverage clearly 
states dentures are covered once every five calendar years. The records do not support that the Plan paid for a 
partial denture within the last 5 years. Therefore, we decided that the Plan has to pre-approve the lower partial 
denture.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical extraction of teeth 20, 21, 26, 28 and 29. 
 
You asked the Plan to pre-approve the extractions. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service requested. 
 
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 extractions. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the available documentation does not support that the extraction of the teeth at issue requires 
removal of bone and/or sectioning of the teeth. 
 
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 extractions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the surgical extraction of teeth 20, 21, 26, 28 and 29.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan of the neck 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the PCP was not able to palpate a lump. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found CT of the neck with 
contrast is an appropriate exam for cervical lymphadenopathy.  The request for CPT 70491 is the correct code.  
CTA of the neck is not indicated in this case and the CPT for CTA of the neck is 70498. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
CT scan of the neck  
 
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 Repatha Sureclick (J3590). 
 
You asked the Plan to pre-approve the Repatha Sureclick. You say that you would like reconsideration because 
this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the 
member's condition under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick (J3590).  
 
Benefits for the Repatha Sureclick may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the two transforminal injections. We decided that the Plan does 
not have to pre-approve two transforminal injections.  
 
You asked the Plan to pre-approve the four transforminal injections. You say that you would like 
reconsideration because you have been in severe pain. The Plan says that procedure requested is not supported 
without a treatment plan showing that you will not exceed Medicare's limits. 
 
We decided that the Plan has to pre-approve the two transforminal injections.  
 
The Plan follows Medicare rules. Medicare rules say that no more than two transforaminal injections may be 
performed at a single setting. 
 
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 four transforminal injections. Our 
reviewer says that a single translaminar epidural steroid injection could provide the same coverage or bilateral 
transforminal injection at a single level would also be within the LCD criteria. Our physician reviewer found 
only up to 2 injections would be considered 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 two transforminal injections have been met. Therefore, we decided that the 
Plan has to pre-approve the four transforminal injections.  
 
We also decided that the Plan does not have to pre-approve two transforminal injections. 
 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health skilled nursing visits. You say that the requested home health 
skilled nursing visits are medically necessary. The Plan denied your request. The Plan says the requested home 
health skilled nursing visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing visits. Our 
reviewer says that the requested home health skilled nursing visits are not medically necessary. Our physician 
reviewer found based on the documentation provided, the enrollee does not appear to be homebound.  The 
enrollee does not have documented skilled nursing needs.  The enrollee does not have documented skilled 
therapy needs.  Therefore, ongoing HHS are not shown to be medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertebral augmentation procedure. 
 
You asked the Plan to pre-approve the vertebral augmentation procedure. You say that you would like 
reconsideration because this service is necessary to treat the member's pain. The Plan denied your request. The 
Plan says the enrollee has lost too much height from these compression fractures for this procedure to be 
indicated. 
 
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 vertebral augmentation procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found Medicare coverage criteria have not been met. Imaging has 
documented an 80% height loss at L3 which is a relative contraindication to this procedure, as well as 
retropulsion of bone. 
 
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 vertebral augmentation procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a vertebral augmentation procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator placement (63688, 63663). 
 
You asked the Plan to pre-approve the spinal cord stimulator placement. You say that the stimulator is 
medically necessary because your current stimulator requires frequent charging. The Plan denied your request. 
The Plan says the current spinal cord stimulator functions properly. The request is for a stimulator that requires 
charging less frequently as a matter of convenience. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for a spinal cord stimulator is limited to 
one permanent spinal cord stimulator per patient per lifetime.  
 
We looked at the file and Medicare rules. The enrollee currently has a spinal cord stimulator but is requesting a 
new one by a different manufacturer. The current unit is noted to be functioning as intended. Based on this 
information, we decided that Medicare rules for coverage of the spinal cord stimulator placement have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator placement 
(63688, 63663).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have had a pre-existing condition for the 
past nine years and you have gotten new inserts every three years to help you walk. You say that you have 
previously checked your benefits and you should have coverage for the requested orthotics. You stated that 
your current inserts were locked up at your work due to Covid-19 layoffs and you have been injured since you 
are unable to wear them. You asked the Plan to reconsider providing coverage for the requested foot orthotics. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast cancer (BRCA) 1 and BRCA 2 testing. 
 
You asked the Plan to pre-approve BRCA 1 and BRCA 2 testing. You say that you would like reconsideration 
based on the medical records provided. The Plan denied your request. The Plan says BRCA 1 and BRCA 2 
testing is not approved because there is no personal history of cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
 
 
 
 
The test at issue in this appeal, BRCA 1 and BRCA 2 testing, is being requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pre-approve breast cancer (BRCA) 1 and BRCA 2 testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro Powered upper extremity range of motion 
assist device. 
 
You asked the Plan to pre-approve the MyoPro. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at this time the requested robotic orthosis is not proven to be more beneficial for treatment of 
your medical condition/function than any available standard therapy. 
 
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 MyoPro have not been met. Therefore, we decided that the Plan does not 
have to pre-approve MyoPro Powered upper extremity range of motion assist device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary. The Plan 
denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's rehab needs can be met at a lower intensity alternate setting such as in 
a Skilled Nursing Facility. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested LTACH care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee's 
ongoing care needs include respiratory support with ventilator management and tracheostomy care, 
surveillance laboratory studies, tube feedings, pressure wound care, and therapy services. The documentation 
does not support that the enrollee in this case requires services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. There are no required medical services identified that are 
available at the LTACH, that are not available at the current health care setting being offered by the health 
plan. The LTACH services are 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee's high functional level does 
not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist. 
The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on 
a "daily basis" in a SNF. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Skilled Nursing Facility (SNF) services.