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

 
We decided that the Plan has to pre-approve an advanced knee ankle system (L5848). 
 
You asked the Plan to pre-approve an advanced knee ankle system. You say that the item is medically 
necessary. The Plan denied your request. The Plan says that the item is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that the records must document the beneficiarys current 
functional capabilities and his/her expected functional potential, including an explanation for the difference, if 
that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often 
cannot be strictly bound by functional level classifications. 
 
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 advanced knee ankle system. Our 
reviewer says that the item is medically necessary. Our physician reviewer found the record indicates the 
enrollee will be a K3 ambulator and will benefit from an advanced knee ankle system. 
 
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 advanced knee ankle system have been met. Therefore, we decided that the 
Plan has to pre-approve an advanced knee ankle system (L5848).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on July 11, 
2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the claim should be paid. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen purchased on May 22, 2022. 
 
You asked the Plan to pay for the portable oxygen. You say that the item should be covered. The Plan denied 
your request. The Plan says purchased oxygen equipment is statutorily non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that A/B MACs (A) or (HHH), and DME MACs may 
not pay for oxygen equipment that is purchased on or after June 1, 1989. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the portable oxygen have not been met. Therefore, we decided that the Plan does not have to pay 
for the portable oxygen purchased on May 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcatheter insertion or replacement of permanent 
leadless pacemaker (33274) provided on June 15, 2022. 
 
You asked the Plan to pay for the leadless pacemaker. You say that the documents support medical necessity. 
You also say that the charges were billed and approved by the Plan. The Plan denied your request. The Plan 
says the service was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that leadless pacemakers are non-covered when furnished 
outside of a CMS approved CED study. 
 
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 leadless pacemaker. Our reviewer says 
that the leadless pacemaker was not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee was enrolled in a CMS approved CED study. Therefore, the 
reviewer found that the service was 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 leadless pacemaker have not been met. Therefore, we decided that the Plan 
does not have to pay for the transcatheter insertion or replacement of permanent leadless pacemaker (33274) 
provided on June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300) and electronic 
connection between wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied 
your request. The Plan says the items are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. A power seat elevation feature 
(E2300) is non-covered because it is not primarily medical in nature. If a wheelchair has an electrical 
connection device described by code E2310 or E2311 and if the sole function of the connection is for a power 
seat elevation or power standing feature, it will be denied as non-covered. Therefore, we decided that the Plan 
does not have to pre-approve the power seat elevation system (E2300) and electronic connection between 
wheelchair controller and two or more power seating system motors (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary due to 
chronic respiratory failure. The Plan denied your request. The Plan says the requested device does not meet the 
requirements for approval. 
 
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 service is not medically necessary. Our physician reviewer found you were given a diagnosis of COPD, 
although the records do not include pulmonary function tests. You were hospitalized for dyspnea in December 
and required intubation. The records do not include an ABG to document CO2 retention. Medicare requires an 
ABG, done while stable and awake, showing increased CO2. If you do have COPD and chronic CO2 retention, 
you may benefit from BiPAP with AVAPS during sleep as an outpatient. Medicare does not cover a home 
ventilator when used to provide settings that can be delivered with BiPAP. 
 
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 (E0466).
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 surgical repair of a hip fracture after a fall. 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance image (MRI) of lower extremity, 
any joint without contrast Material (73721). 
 
You asked the Plan to pre-approve an MRI of lower extremity. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the request does not meet the Medicare or health plan coverage 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of lower extremity. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee presented 
with left hip pain with an onset of severe months ago. The pain is now daily with walking. She has difficulty 
with lifting the left leg into the car when she is driving. The exam reveals a limp with ambulation. There is left 
anterior/lateral pain. However, detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures. She is noted to have only tried over-the-
counter analgesics. Additionally, the x-rays dated January 23, 2023, showed advanced osteoarthrosis of the left 
hip. The objective exam did not demonstrate findings indicative of any other pathologies (i.e., labral pathology) 
that would plausibly require more advanced imaging without failure of conservative measures. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested MRI of the lower extremity, any joint without contrast 
material, in this case, 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 an MRI of lower extremity have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance image (MRI) of lower extremity, any joint without 
contrast Material (73721).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endocrinology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you need the best medicine to treat your 
condition. The Plan denied your request. The Plan says you must use network providers to get your medical 
care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these OON services. Therefore, we decided that the Plan does not have to pre-approve endocrinology 
services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the elotuzumab (J9176) provided on February 9, 2022. 
 
You asked the Plan to pay for the elotuzumab. You say that this should be covered. The Plan denied your 
request. The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pay for the elotuzumab. Our reviewer says that 
elotuzumab was medically necessary. Our physician reviewer found this drug is supported for the enrollee's 
condition in this case. Therefore, the reviewer found that the elotuzumab was medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the elotuzumab have been met. Therefore, we decided that the Plan has to pay 
for the elotuzumab (J9176) provided on February 9, 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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 appears to be improving with current treatment and should only 
require short-term additional acute-care services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current facility. 
 
 
  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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandible bone graft (21215), provided on March 1, 2022. 
 
You asked the Plan to pay for the mandible bone graft. You say that the service should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 the 
mandible bone graft (21215), provided on March 1, 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 is stable and suitable for 
transfer to an LTACH. You say the enrollee requires prolonged hospitalization and close physician monitoring. 
The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility. There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this 
time and completion of treatment at the current facility is 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 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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 enrollees has complex functional impairments and active medical issues 
however, evaluating therapists document poor activity tolerance and participation thus the enrollee would not 
be expected to tolerate 15 hours of therapy per week or intensive therapy. While the medical record supports a 
need for physical or occupational therapy medically necessary care can be provided in a different level of 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 pre-approve a portable gaseous oxygen system (E0431) and oxygen 
concentrator (E1390). 
 
You asked the Plan to pre-approve a portable gaseous oxygen system and oxygen concentrator. 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. Medicare rules say that there is no further payment for oxygen 
equipment during the 5-year reasonable useful lifetime (RUL) of the equipment after 36 rental payments have 
been made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable gaseous oxygen system and oxygen concentrator have not been met. Specifically, the 
rental started on June 29, 2020, therefore the Plan will cover the rental for the requested equipment until June 
29, 2023. Coverage does not extend past the 36-month rental period. Therefore, we decided that the Plan does 
not have to pre-approve a portable gaseous oxygen system (E0431) and oxygen concentrator (E1390).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography 
(CPT code 93458). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says left heart catheterization is needed for patients with high-risk findings on 
stress testing or computed tomography (CT) scans. The Plan states the enrollee does not meet these criteria. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient documentation to support the medical necessity of cardiac catheterization in 
this enrollee's 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve catheter placement in coronary artery(s) for coronary angiography, including 
intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart 
catheterization including intraprocedural injection(s) for left ventriculography (CPT code 93458).