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

 
We decided that the Plan does not have to pre-approve a JACO V2 robotic arm. 
 
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 item is 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. The file shows that 
the item is used primarily for convenience actions. Therefore, we decided that the Plan does not have to pre-
approve a JACO V2 robotic arm.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Advocate Redi Code Plus diabetic testing supplies. 
 
You asked the Plan to pre-approve Advocate Redi Code Plus diabetic testing supplies. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be 
provided by a preferred brand. 
 
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 
Advocate Redi Code Plus diabetic testing supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three further speech therapy visits. 
 
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 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 these services. 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 note dated July 30, 2020 shows that the enrollee was on regular 
textures and needed minimal to close supervision for swallowing and drinking thin liquids. There was skilled 
patient and caregiver instructions. The records do not support that the requested speech therapy visit are 
generally accepted as specific and effective therapy for the patient's condition. The enrollee does not require the 
unique skills of a professional therapist to safely and effectively provide treatment. The services are not part of 
a maintenance program and are not needed to design and/or deliver a program to maintain the enrollee's 
condition or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve three further speech therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute, also known as a knee 
walker/scooter, coded as E0118. 
 
You asked the Plan to pre-approve the knee scooter. You say that you feel that this should be covered. The Plan 
denied your request. The Plan says this is not an item that is covered by Medicare at this time. 
 
The Plan must follow Medicare rules. The DME MAC has determined that there is not sufficient evidence to 
support the medical necessity of a knee scooter at this time. Therefore, we decided that the Plan does not have 
to pre-approve a crutch substitute, also known as a knee walker/scooter, coded as E0118.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 additional HBO therapy services (G0277 and 
99183). 
 
You asked the Plan to pre-approve the additional HBO services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says a re-assessment of improvement is 
needed for additional treatments. 
 
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 additional HBO services. Our 
reviewer says that Medicare guideline state that response to therapy should be evaluated at least every 30 days 
during administration of HBO therapy. Our physician reviewer found continued treatment with HBO therapy is 
not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. 
Because the results of initial therapy are not reported, the additional 30 HBO treatments are not medically 
reasonable and necessary. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional HBO services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 30 additional HBO therapy services (G0277 and 99183).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says you do not have any qualifying diagnosis and do not require intense care coordination. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request (transportation for non-medical needs, allowance for healthy food purchases and/or 
electricity, water and/or phone bill payments, home assistance services), the records in the case file, and the 
rules. Based on this information, we decided that the Medicare rules for coverage of the services have not been 
met. None of these services are medical services that can be paid for by the plan. Therefore, we decided that the 
Plan does not have to pre-approve special supplemental benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker (E0143). 
 
You asked the Plan to pre-approve an upright walker. You say that you were told this would be covered. The 
Plan denied your request. The Plan says your needs are met by your current walker. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a four-wheeled walker. a four-wheeled walker serves the same purpose as an 
upright walker. Therefore, we decided that the Plan does not have to pre-approve an upright walker (E0143).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan of the brain. 
 
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 a brain PET is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has complaints of memory 
problems and an electroencephalogram (EEG) showed global slowing. Her presentation is more suggestive of 
Alzheimer's disease (versus a vascular dementia), rather than frontotemporal dementia (FTD). The complaints 
and presentation are otherwise inconsistent with FTD. The records do not support that the enrollee meets the 
criteria for coverage. The requested brain PET 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 positron emission tomography (PET) scan of the brain.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate procedure. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because medical 
studies have not proven that the use of this procedure is helpful for treatment of the enrollee's condition. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion surgery. More 
research is needed to show its safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate procedure.
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 walking is painful. The Plan denied your 
request. The Plan says you do not have a documented diabetic foot disease. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249). 
 
You asked the Plan to pre-approve clinical crown lengthening. You say that this should be covered. The Plan 
denied your request. The Plan says this 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
clinical crown lengthening (D4249).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). You say that the enrollee has abfraction on tooth #12 
which presents as subcrestal caries on radiographs. You say that it can be restored to optimal strength and 
function with a full coverage restoration and buildup. The Plan denied your request. The Plan says 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. The Plan denied your request. The Plan says the service is 
not covered by Medicare or your plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for diabetic shoe inserts with an out-of-
network provider at the in-network benefit level. 
 
You asked the Plan to pre-approve the referral. You say that you do not want to receive your inserts from a 
provider that is located within a grocery store. The Plan denied your request. The Plan says there is a 
participating provider 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 this referral at the in-network benefit level. If the services are received from this 
provider, it will be paid at out-of-network benefit level. Therefore, we decided that the Plan does not have to 
pre-approve a referral for diabetic shoe inserts with an out-of-network provider at the in-network benefit level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultraviolet (UV) light cabinet. 
 
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 item is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that ultaviolet cabinets are covered for selected patients 
with generalized intractable psoriasis. 
 
We looked at the file and Medicare rules. The file does not show that the enrollee has generalized intractable 
psoriasis. 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 an ultraviolet (UV) light cabinet.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the wheelchair and accessories. You say that you would like reconsideration 
because the wheelchair is medically necessary. The Plan denied your request. The Plan says you do not meet 
medical necessity criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair and accessories. Our 
reviewer says that the documentation does not reveal physician office notes that indicate you have a mobility 
limitation that significantly impairs your ability to participate in one or more mobility-related activities of daily 
living (MRADLs). Our physician reviewer found your mobility limitation may be able to be alleviated with a 
walker or possibly a manual wheelchair. There is no physician neuromuscular evaluation of the upper and 
lower extremities indicating why you are unable to use your upper extremities for an assistive device. There is 
no evidence of edema therefore the request for power elevating leg rests is not supported. You not utilize 
intermittent catheterization for bladder management and can transfer independently. 
 
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 wheelchair and accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a group 2 power wheelchair and accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the upper 
extremity (73221). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 
MRI is not medically necessary. Our physician reviewer found the enrollee had not yet tried and failed a 
sufficient amount and duration of formal physical therapy or NSAIDs for the left shoulder injury. Also, x-rays 
were not ordered which would be appropriate prior to considering more advanced imaging. No physical 
findings revealed a red flag diagnosis which would negate these requirements. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve Magnetic Resonance Imaging (MRI) of the upper extremity (73221).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that you need a family member to help 
you on a daily basis. The Plan denied your request. The Plan says care must be received from a recognized 
provider who is eligible to provide these services with Medicare. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you receive your care from a provider who is eligible to provide services under Original 
Medicare. 
 
The requested provider in this case is not a network provider with the Plan, nor eligible to provide services 
under Original Medicare. The Plan has network providers available who can provide the services at issue in 
this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we 
decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy visits 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 has 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 
physical therapy visits 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 shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have fear of falling in the tub or shower. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan of the chest for the enrollee. 
 
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 this test should be used once twelve months after a spot was noticed. 
 
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 that ordinarily, a CT of 
the chest is not necessary for following a 5 mm nodule. However, this enrollee has 2 criteria for the requested 
CT of the chest. First, he is high risk for lung cancer due to his smoking history and second, he has known 
COPD as well as the symptom of persistent cough which makes him symptomatic.  The presence of his 
symptoms and known pulmonary nodule would disqualify him for a low dose lung CT which would ordinarily 
be indicated due to smoking history.  So, based upon his history and symptoms he qualifies for a 1-year follow 
up CT of the chest. 
 
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 chest for the enrollee.  
 
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.