Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a single photon emission computed tomography (SPECT) scan. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show any signs/symptoms due to amyloid transthyretin (ATTR). 
 
The Plan must follow Medicare rules. Medicare rules say that SPECT 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 the enrollee has 
progressive decreasing left ventricular ejection fractions: 71% 2017, 65% 2019 and 59% 2021.  She has a left 
bundle branch block and aortic valve disease.  All of these factors may be seen with a type of Amyloid ATTR. 
Lab values looking for light chains and urine for immunofixation have been ordered but lab values are not in 
the submitted records. A review of the literature indicates this patient's symptoms may be associated with 
Amyloid infiltration of the myocardium. It should be noted that not all such cases show abnormal lab values 
and cardiac SPECT imaging is suggested when clinical history is consistent with the diagnosis. The cardiology 
consult detailed the patient's history and clinical evaluation as being consistent with Amyloid ATTR.  Based on 
these factors Cardiac SPECT imaging is reasonable and should be 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 the scan have been met. Therefore, we decided that the Plan has to pre-approve 
a single photon emission computed tomography (SPECT) scan.  
 
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 the pneumatic compression device (PCD) rendered on March 
1, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. The file shows that there two separate delivery tickets; therefore, the 
delivery date cannot be substantiated. 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 pay for the pneumatic 
compression device (PCD) rendered on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0003, E0978, E0971, K0108). 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the manual wheelchair is medically 
necessary. The Plan denied your request. The Plan says the enrollee already has equipment that serves the same 
purpose. 
 
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 the enrollee has a power wheelchair. The power wheelchair serves the same purpose as the 
requested manual wheelchair. Therefore, we decided that the Plan does not have to pre-approve a manual 
wheelchair (K0003, E0978, E0971, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says you do not meet coverage criteria for 
the requested CGM and supplies. 
 
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 a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 28, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
February 28, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless they are authorized by the Plan before the 
services are provided. 
 
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 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 subsequent nursing facility care provided on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested spinal cord stimulator is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested spinal cord stimulator. 
 
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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet criteria for the requested spinal cord stimulator. Our physician reviewer 
found the use of a spinal cord stimulator to treat diabetic peripheral neuropathy is NOT evidence based. There 
are several other evidence-based therapies that have NOT been tried here. Psychological evaluation may be 
performed by a physician or a psychologist. The request is NOT medically reasonable or 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on June 21, 2022. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you do not feel the Plan was 
charged correctly. 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 a $60 
copayment for Podiatry services. 
 
You have been asked to pay a $60 copayment for specialist visit. This item/service falls within the Podiatry 
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 copayment for specialist visit provided on 
June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you disagree with the denial. You been a 
diabetic now for almost 20 years and your fingers have been poked at for so many years. You also say your 
provider has recommended this device as you now check your levels up to 6 times a day. The Plan denied your 
request. The Plan says you do not meet coverage criteria for the requested CGM and supplies. 
 
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 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 a CGM and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (62323). 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says this request is denied because it does not meet the 
coverage guidelines. 
 
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 epidural steroid injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of chronic low back pain with radicular 
symptoms left lower extremity due to degenerative lumbar disc disease.  He has had medical therapy with MS 
Contin and Tylenol with Codeine.  There was no documentation of the response to his last injection. According 
to the coverage criteria, a repeat ESI, when the first injection directly and significantly provided improvement 
of the condition being treated, may be considered medically reasonable and necessary when the medical record 
documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from 
baseline using the same scale for at least three months. If the enrollee fails to respond well to the initial ESI, a 
repeat ESI after 14 days can be performed, using a different approach, level and/or medication if appropriate, 
with the rationale and medical necessity for the second ESI documented in the medical record. The review has 
determined that the enrollee does not meet the coverage criteria for the requested repeat ESI. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that your blood sugars are fluctuating a lot due to your 
chemotherapy diet. You state that you are not able to use your current device because of your poor vision. You 
believe having the CGM will be helpful and is medically necessary. The Plan denied your request. The Plan 
says criteria for a CGM are not met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on May 
25, 2022, to May 27, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this inpatient stay was 
not anticipated. You say you went for an outpatient procedure but had to be admitted anyway. 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 a $175 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-
network.  
 
You have been asked to pay a $175 copayment per day for days 1-2 for an inpatient hospital stay. The total 
amount you are being asked to pay is $350 ($175 x 2 days = $350). This item/service falls within the inpatient 
hospital care/in-network 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 copayment for an inpatient 
hospital stay provided on May 25, 2022, to May 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that because of the enrollee's cerebral 
aneurysm, he can neither stand nor walk. The Plan denied your request. The Plan says the request for a seat lift 
mechanism is not reasonable and necessary because the records show no evidence that the enrollee is able to 
ambulate once standing and therefore, does not meet Medicare coverage guidance. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a seat lift mechanism. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found provided records 
document hypertension, hyperlipidemia, and right hemiparesis due to a prior stroke with gait 
impairment. The seat lift is included in the treating practitioner's course of treatment. The provider does request 
the seat lift to effect improvement in the enrollee's condition or to arrest or retard deterioration in the enrollees 
condition. The records show that the enrollee is completely incapable of standing from a chair in the home. The 
records also show that he does not have the ability to ambulate. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components and accessories, custom fabricated (L8702). 
 
You asked the Plan to pre-approve a MyoPro device. You say that the device is medical necessary, and the 
device is deemed safe and effective. The Plan denied your request. The Plan says the MyoPro orthosis is 
considered experimental, investigational and unproven when used to help restore function to arms and hands 
paralyzed or weakened by CVA stroke, brachial plexus injury, cerebral palsy or any other neurological or 
neuromuscular disease or injury. 
 
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 MyoPro device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, 
single or double upright(s), includes microprocessor, sensors, all components and accessories, custom 
fabricated (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the hospital bed. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, 
E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. The requested total electric hospital bed is not covered per LCD 
L33820. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed 
(E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mobile dialysis services provided on June 10, 2022 to June 
20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON mobile dialysis services. You say that this patient needed to be dialyzed 
immediately upon admission, so it was not safe to transport her to a network facility. The Plan denied your request. The Plan says you did not have authorization to provide these OON services and in-network providers 
were available.  The Plan also says that you are not a Medicare-certified 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. Medicare rules also say that Plans cannot pay non-Medicare 
certified providers. 
 
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 mobile dialysis services provided on June 10, 
2022 to June 20, 2022, by an out-of-network (OON) provider.