Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services (97530-GPKX x2, 97116-
GPKX x1, 97530-GPKX x3, 97116-GPKX x1, 97530-GPKX x3, 97116-GPKX x1, 97530-GPKX x3, 97116-
GPKX x1, 97116-GPKX x1, 97530-GPKX x3, 97116-GPKX x1, and 97530-GPKX x3) provided from June 7, 
2021, to June 29, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the physical therapy services have 
been met. The medical records submitted only contain occupational therapy records. There were no physical 
therapy records provided to verify the services billed from June 7, 2021, to June 29, 2021. Therefore, we 
decided that the Plan does not have to pay for the physical therapy services (97530-GPKX x2, 97116-GPKX 
x1, 97530-GPKX x3, 97116-GPKX x1, 97530-GPKX x3, 97116-GPKX x1, 97530-GPKX x3, 97116-GPKX 
x1, 97116-GPKX x1, 97530-GPKX x3, 97116-GPKX x1, and 97530-GPKX x3) provided from June 7, 2021, 
to June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Apple watch, purchased on September 3, 2022. 
 
You asked the Plan to pay for an Apple watch. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an Apple watch, purchased on 
September 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transoral outlet reduction (TORe) procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure manages weight 
recidivism following roux en y gastric bypass (RYGB) surgery. The Plan denied your request. The Plan says 
the procedure 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 the requested services. Our physician 
reviewer found that the enrollee has a history of morbid obesity who underwent a roux en y gastric bypass 
(RYGB) in 2005. The enrollee has had weight regain. He has made some dietary efforts including Saxenda but 
unclear if he has worked with a multidisciplinary team recently. The requested TORe procedure has not been 
shown in any clinical trial or high level prospective published literature to provide durable weight loss. The 
TORe procedure is an endoscopic procedure most commonly used for outlet reduction. Per medical records, 
this enrollee already has a smaller than normal outlet of 12 mm. Therefore, the requested procedure is not 
determined to be medically necessary for this 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transoral outlet reduction (TORe) procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve morphine sulfate, extended release (ER) tablet. 
 
You asked the Plan to pre-approve morphine sulfate. You say that the requested drug is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. 
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the requested drug is not covered 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 morphine sulfate, extended 
release (ER) tablet.  
 Benefits for morphine sulfate 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the documentation does not support that the requested device is medically reasonable or necessary. Our 
physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) and a history of lung 
cancer. The enrollee was recently hospitalized with influenza pneumonia, and arterial blood gas was consistent 
with acute on chronic hypercarbic respiratory failure. The enrollee improved on BiPAP in the hospital.  This enrollee may benefit from BiPAP with average volume-assured pressure support and a backup rate during 
sleep. Medicare does not cover a home ventilator when used as BiPAP. Therefore, the enrollee does not meet 
criteria for the requested device. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78608). 
 
You asked the Plan to pre-approve a PET scan. You say that you want the Plan to approve the service. The Plan 
denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a PET scan have been met. There are 
no medical records within the casefile. Without the requested clinical information, we are unable to determine 
if the requested services are medically necessary. Therefore, we decided that the Plan does not have to pre-
approve a positron emission tomography (PET) scan (78608).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the goal is to control pulmonary artery 
pressures and to reduce heart failure hospitalizations. The Plan denied your request. The Plan says the device 
has been determined to be of uncertain value. 
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). The clinical study on which the 
Food and Drug Administration (FDA) approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted. Subsequent follow-up studies 
remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In 
addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Sprint peripheral nerve stimulation (PNS). 
 
You asked the Plan to pre-approve Sprint PNS. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Sprint PNS systems are only covered for certain 
indications. Therefore, we decided that the Plan has to pre-approve Sprint peripheral nerve stimulation (PNS).  
 
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 pay for a pneumatic compression device (E0675) and suspension 
sleeve (E0673), provided on July 11, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says these items are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease or in a surgical center. 
 
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. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and suspension sleeve (E0673), provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on 
May 9, 2022. 
 
You asked the Plan to pay for the dental service. You say that you need the dental services approved. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because the unspecified 
preventive procedure is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified preventive procedure (D1999) provided on May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and self-care management training provided 
on September 26, 2022. 
 
You asked the Plan to pay for an office visit and self-management training. You say that the services were 
medically necessary and provided in good faith. The Plan denied your request. The Plan says the enrollee must 
receive care from a network provider. 
 
 
 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 had network providers 
available who could have provided 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 an office visit and self-care management training 
provided on September 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has met all required 
qualifications and LTACH services are their best option for recovery. The Plan denied your request. The Plan 
says the requested LTACH services do not meet the requirements for approval. 
 
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 considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. All medically necessary care is being 
provided in the current acute care setting. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee fully meets the Medicare guidelines for 
IRF admission. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were 
not 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 in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation does not specify any complex deficits (admitting 
diagnosis is neuro but impairment is left hip hematoma thus incorrectly coded) or active medical comorbidities 
thus the complexity of the patient's nursing, medical and rehabilitation needs would not be expected to require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and suspension 
sleeve (E0673), provided on June 6, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says these items are not covered for preventions of venous 
thromboembolism nor for treatment of peripheral artery disease or in a surgical center.  
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. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and suspension sleeve (E0673), provided on June 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
monitor would be redundant at this time. 
 
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 requested services. Our physician 
reviewer found that while the enrollee is being assessed for Paroxysmal supraventricular tachycardia (PSVT), 
there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any 
other apparent indication for an ILR. In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR in this enrollees clinical management. Therefore, the requested service is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantable loop recorder (ILR).
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 the services are medically necessary for 
the enrollee to receive help managing their complex medical needs. The Plan denied your request. The Plan 
says the services can be received in the current acute care facility. 
 
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 considered medically reasonable and necessary in this case. Our 
physician reviewer found all medically necessary care is being provided in the current acute care setting. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. The health plan has approved ongoing care in the current acute care setting.  
 
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a therapeutic continuous glucose 
monitor (CGM). 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that the supply allowance for the 
CGM is medically necessary. The Plan denied your request. The Plan says there is no information submitted to 
consider this charge without the proper treatment records. 
 
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 pay for the CGM. Our reviewer says that the supply 
allowance for the CGM is not medically necessary. Our physician reviewer found that in this case, the record 
indicates that the enrollee has diabetes. The record does not indicate that enrollee is insulin-treated with 
multiple (3 or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) 
pump; and that the enrollees insulin treatment regimen requires frequent adjustment by the enrollee on the 
basis of the testing results. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
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 pay for the supply allowance for a therapeutic continuous glucose monitor (CGM).