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

 
We decided that the Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle (POV) 
and a sealed lead battery. 
 
You asked the Plan to pre-approve the POV and lead battery. You say that a heavy duty POV is medically 
necessary due to the enrollee's height. The Plan denied your request. The Plan says that the requested items are 
not medically necessary. 
 
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 patients 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 POV and lead battery. Our reviewer 
says that that the coverage criteria has not been met. Our physician reviewer found that the enrollees weight is 
not provided. Without specification of the enrollees weight, the provided documentation does not support the 
enrollee requires a heavy duty POV. As the necessity of the POV is not supported in the documentation, the 
requested sealed lead battery is not covered. 
 
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 POV and lead battery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle (POV) and a sealed lead 
battery.
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 the shower chair is necessary for safety reasons 
and not due to hygiene. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
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 wheelchair accessory, manual swingaway, retractable 
or removable mounting hardware for joystick, other control interface or positioning accessory (E1028) and 
repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a 
technician, labor component, per 15 minutes (K0739). 
 
You asked the Plan to pre-approve a wheelchair accessory and labor component. You say that the requested 
DME is medically necessary because the enrollee's head control is poor and total contact head support is 
needed for all positions. You also say the swing away elbow supports allow improved Hoyer transfer with less 
equipment breakage and correct positioning based on tilt and recline. The removeable hardware for hip "glides" 
allows safe transfers and positioning to correctly support the enrollee's pelvis and femurs. The Plan denied your 
request. The Plan says the enrollee needs a one person assist with a mechanical lift to complete transfers. The 
documentation submitted does not show the request for E1028 is to move the component out of the way so that 
the enrollee can perform a slide transfer to a chair or bed. The Plan cannot cover K0739 as the cost for this 
code should be factored into the DME provider's cost of doing business. 
 
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 wheelchair accessory and labor 
component. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is a request for these additional accessories to be 
added to current manual tilt-in-space. Per documentation, the functional mobility & wheelchair assessment on 
June 1, 2022, reveals that transfers are with one person assist with mechanical enrollee lifts. Criteria has not 
been met for the E1028 as there is no indication that this is needed for moving hardware out of the way for a 
slide transfer to chair or bed. As the E1028 is not medically necessary the repair or nonroutine service for 
durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, 
per 15 minutes 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 a wheelchair accessory and labor component have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, manual swingaway, retractable or 
removable mounting hardware for joystick, other control interface or positioning accessory (E1028) and repair 
or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a 
technician, labor component, per 15 minutes (K0739).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Sensor. You say that the medical records provided 
support the need for the requested service. The Plan denied your request. The Plan says the enrollee does not 
require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Sensor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75710 and 75774 billed for date of service 
June 29, 2022. 
 
You asked the Plan to pay for procedure codes 75710 and 75774. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says procedure codes 75710 and 75774 are bundled 
into the payment for procedure code 37225. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 75710 and 75774 are column II codes to column I code 37225; 
however, codes 75710 and 75774 were billed with a modifier.  
 
We asked our coder 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 procedure codes 75710 and 75774. Our reviewer says that 
procedure codes 75710 and 75774 do not meet criteria for payment. Our reviewer found that the operative 
report describes angiography and intervention performed. In this case, angiography services would not be 
reported separately, as they would be inclusive to the intervention, which in this case is procedure code 37225. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 75710 and 75774 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 75710 and 75774 billed for date of service June 29, 
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 you are requesting reconsideration of 
this denial based on the enrollee's condition and your strong recommendation that the LTACH is the most 
appropriate level of care for this enrollee. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare guidelines for admission to an LTACH. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electroencephalogram (EEG) extended monitoring; 
41-60 minutes (95812) and an electroencephalogram (EEG); including recording awake and asleep (95819). 
 
You asked the Plan to pre-approve an electroencephalogram. You say that services are medically necessary. 
The Plan denied your request. The Plan says the request is not medically necessary. The records do not show 
that the enrollee is suspected of having a seizure or that the enrollee is suspected of having dementia. A recent 
review of the diagnosis of dementia does not include electroencephalogram as part of the diagnostic work-up of 
dementia. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electroencephalogram. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is being evaluated for dementia. The enrollee is not readily suspected of 
having seizures, a seizure disorder or epilepsy. In as much, the enrollee would not meet the LCD requirements 
for performance of an EEG. Nor would this request be readily consistent with standards of care/practice in the 
evaluation of dementia. Such testing has not been shown to yield any clinical improvements or diagnostic 
accuracy with regards to dementia. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electroencephalogram have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an electroencephalogram (EEG) extended monitoring; 41-60 minutes 
(95812) and an electroencephalogram (EEG); including recording awake and asleep (95819).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0856, E0955, 
E1002, E1012, E1028, E2311, E2361, E2620, E2622, K0108). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the wheelchair you now 
have does not work well and it causes you pain when trying to maneuver around. You need a new wheelchair. 
The Plan denied your request. The Plan says you do not have a medical need for a group 3 power wheelchair 
(PWC) with the requested power options/features. 
 
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 patients 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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found you are able to 
stand with assistance, are at low risk for skin breakdown, you do not use a catheter, and you do not have 
spasticity which limits your positioning. You do not have a medical need for the requested wheelchair and 
accessories. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0856, E0955, E1002, E1012, 
E1028, E2311, E2361, E2620, E2622, K0108).
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 enrollee needs LTACH care. The 
Plan denied your request. The Plan says an LTACH admission 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 considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that are currently not being 
provided but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that this drug has worked well for the 
enrollee. The Plan denied your request. The Plan says this drug is not covered by 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 Synthroid tablets.  
 
Benefits for self-administered drug 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: 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 you are requesting reconsideration of 
the denial for an LTACH admission and have enclosed supporting clinical documentation for review. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for admission to an LTACH. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for urgent services provided on June 25, 2022, 
to July 13, 2022. 
 
You asked the Plan to waive the cost share for urgent services. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly.  
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 
copayment for Urgently needed services.  
 
You have been asked to pay $20 copayment for each urgent service. This item/service falls within the Urgently 
needed services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the cost share for urgent services provided on 
June 25, 2022, to July 13, 2022.  
 
Please note that neither you nor the Plan are responsible for paying the balance bill. Please contact the 
provider about a refund for any amount you paid above the Medicare allowable amount for the urgent care 
visits. If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the 
Plan directly.
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 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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of a stroke, 
altered mental status, obstructive sleep apnea, and is intolerant to continuous positive airway pressure (CPAP) 
therapy. The enrollee has recently hospitalized with sepsis, altered mental status, acute kidney failure, and 
respiratory failure. There is no diagnosis of chronic obstructive pulmonary disease (COPD), thoracic restrictive 
disease, or generalized neuromuscular disease. There is no diagnosis of COPD, thoracic restrictive disease, or generalized neuromuscular disease. Of note, the records indicate that the patient is not capable of removing a 
mask interface on his own. He has not been shown to fail bi-level positive airway pressure (BiPAP) therapy; 
however, there is a safety concern with any form of noninvasive ventilation if he is not able to remove the mask 
interface on his own. Medicare does not cover a home ventilator when used as BiPAP, or for the diagnoses of 
stroke and heart failure. 
 
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 home ventilator.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee was admitted for encephalopathy, pneumonia, COVID 19 infection, and 
fluid overload. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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.