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

 
We decided that the Plan does not have to pre-approve a right-hand custom silicone finger prosthesis. 
 
You asked the Plan to pre-approve a right-hand custom silicone finger prosthesis. You say that the enrollee's 
current device is so worn out that it no longer functions in the matter in which it is intended. You say that the 
requested device is medically necessary. The Plan denied your request. The Plan says the requested prosthesis 
is not reasonable and necessary, as it exceeds your needs. 
 
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 right-hand custom silicone finger 
prosthesis. Our reviewer says that a right-hand custom silicone finger prosthesis is not considered medically 
reasonable and necessary in this case. Our physician reviewer found a right-hand custom silicone finger 
prosthesis exceeds your medical need. The requested prosthesis is not medically necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a malformed body member. The requested 
passive prosthesis has features that exceed your medical need and are not medically necessary for diagnosis, 
treatment, or function. The ARTech custom painted finger prosthesis website states that, "All finger prostheses 
have custom made acrylic fingernails." Additionally, a review of the specifications reveals that the item exceeds your functional needs. The website also states, "through high density casting, a silicone positive model 
is produced which has all three-dimensional details such as lines, wrinkles and veins as well as the interior 
socket. Final detailing such as hair, freckles, age spots, etc. is achieved by painting with 100% silicone paints." 
 
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 right-hand custom silicone finger prosthesis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a right-hand custom silicone finger prosthesis.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a pneumatic compression device (E0651) and a segmental 
pneumatic appliance, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee has had a 4-
week trial of diuretics that were not effective. The records also show that the enrollee has tried compression 
garments, regular exercise, and elevation. She states the OT records also show that the enrollee has tried the 
device and it was helpful in reducing the swelling. She states this is an essential treatment for the enrollee's 
lymphedema. The Plan denied your request. The Plan says that although the provider indicates a trial of the 
device was done, the occupational therapy (OT) notes received do not show a trial of the device but do show 
the enrollee responded well to bandaging and that compression garments have been ordered. Therefore, the 
coverage criteria specified in the LCD have not been met, and the requested items cannot be approved. 
 The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a pneumatic compression device. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found clinical documentation shows that the enrollee has undergone trial of high dose 
diuretics, lymph edema wrapping and pumps without improvement. The enrollee has documented skin 
breakdown with lymphorrea thus E0651 and an E0667 are 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 pneumatic compression device have been met. Therefore, we decided that the 
Plan has to pre-approve a pneumatic compression device (E0651) and a segmental pneumatic appliance, full 
leg (E0667).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture. 
 
You asked the Plan to pre-approve acupuncture. You say that your PCP recommended acupuncture to help treat 
your migraines. The Plan denied your request. The Plan says acupuncture is only covered for the treatment of 
low back pain and medical records submitted confirmed the acupuncture is for headaches. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture is only covered for the treatment of low 
back pain and medical records submitted confirmed the acupuncture is for headaches. Therefore, we decided 
that the Plan does not have to pre-approve acupuncture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup. 
 
You asked the Plan to pre-approve a battery backup. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a battery backup.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuproux rearward sliding shower, commode and 
mobility assist transfer system (E1399). 
 
You asked the Plan to pre-approve miscellaneous durable medical equipment. You say that the enrollee's 
secondary insurance requires a denial from the primary insurance in order to review for secondary 
authorization. The Plan denied your request. The Plan says the Nuproux rearward sliding shower, commode, 
mobility assist transfer system is nonmedical equipment, and therefore not covered by Medicare. Hygienic 
equipment is deemed as comfort/convenience items are not considered medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve Nuproux rearward sliding shower, commode and mobility 
assist transfer system (E1399).
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the outpatient therapy services. We decided that the Plan does not have 
to pay for the self-administered drugs.  
 
You asked the Plan to pay for the services provided. The Plan says that the claim processed correctly. 
 
We decided that the Plan has to further pay for the outpatient therapy services.  
 
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 $40 
copay for outpatient rehabilitation services.  
 
The Plan says you must pay $93.08 for the outpatient therapy services provided. Based on the Plan contract, 
however, you cannot be asked to pay more than $40 for the services provided. Therefore, we decided that the 
Plan has to pay for the outpatient therapy services provided on January 6, 2021.  
 
We also decided that the Plan does not have to pay for the self-administered drugs or further pay for the 
outpatient surgery services. 
 
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 a $345 
copay for outpatient surgery. You have been asked to pay a $345 copay for the surgery services provided. The 
services fall within the outpatient surgery 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 further pay for the 
outpatient surgery services provided on January 5, 2021. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Drugs that are provided in an outpatient hospital setting, that are usually self-administered, 
are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not 
have to pay for the self-administered drugs provided from January 5, 2021, to January 6, 2021. 
 
Benefits for the services provided may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights. 
 
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: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 49020. We decided that the Plan does not have to pay for code 
49084.  
 
You asked the Plan to pay for the services. The Plan says that the billed services are not supported. 
 
We decided that the Plan has to pay for code 49020.  
 
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, the CPT Code Manual definition of code 49020 is Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open. 
 
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 code 49020. Our reviewer says that the use of code 49020 is 
supported by the records provided. Our reviewer found that there are no NCCI edits between procedure code 
49020 and 44320. The documentation does support the use of procedure code 49020 based on the surgery 
description by the provider and removing infectious material. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 49020 have been met. Therefore, we decided that the Plan has to pay for 
code 49020 billed on February 7, 2022.  
 
We also decided that the Plan does not have to pay for 49084. 
 
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, the CPT Code Manual definition of code 49084 is Peritoneal lavage, including imaging guidance, 
when performed. 
 
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 for code 49084. Our reviewer says that code 49084 is not supported by 
the documentation provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 49084 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 49084 billed on February 7, 2022. 
 
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: 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency medical transportation (NEMT). 
 
You asked the Plan to pre-approve non-emergency medical transportation. You say that the service is 
necessary. The Plan denied your request. The Plan says they reached out to the provider multiple times to 
obtain the PCS form and medical records and did not receive anything. 
 
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 non-emergency medical transportation 
(NEMT) have been met. No medical records or PCS form was submitted by the provider. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency medical transportation (NEMT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 14 day sensor kit. 
 
You asked the Plan to pre-approve FreeStyle Libre 14 day sensor kit. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of FreeStyle 
Libre 14 day sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve 
FreeStyle Libre 14 day sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided on January 31, 2022, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2 (K0553). 
 
You asked the Plan to pre-approve FreeStyle Libre 2. You say that you are appealing the denial of the 
FreeStyle Libre 2. The Plan denied your request. The Plan says the records do not support that the enrollee 
meets the medically necessary criteria. 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of FreeStyle Libre 2 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve FreeStyle Libre 2 (K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve daratumumab and bortezomib. 
 
You asked the Plan to pre-approve daratumumab and bortezomib. You say that the requested daratumumab and 
bortezomib are medically necessary. The Plan denied your request. The Plan says the requested daratumumab 
and bortezomib are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 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 daratumumab and bortezomib. Our 
reviewer says that the requested daratumumab and bortezomib are not medically necessary. Our physician 
reviewer found the requested daratumumab and bortezomib are not a first line regimen. The requested use is 
not FDA approved. This is only approved as subsequent therapy, thus this request for first line treatment is not 
medically necessary, compendia supported, or literature approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of daratumumab and bortezomib have not been met. Therefore, we decided that 
the Plan does not have to pre-approve daratumumab and bortezomib.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional routine transportation miles (A0170). 
 
You asked the Plan to pre-approve 15 additional miles. You say that you need additional mileage. You say that 
you live so far from your doctor. You also say that there are no other doctors closer for you as you live so far 
out in the country. The Plan denied your request. The Plan says additional mileage beyond the 50 allowed per 
trip are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each trip is within 50 miles of driving distance.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, mileage over the 
allowed 50 miles per trip are not covered. Therefore, we decided that the Plan does not have to pre-approve 15 
additional routine transportation miles (A0170).