Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents via a 
controlled release vehicle into diseased crevicular tissue, per tooth (D4381) and gingival irrigation  per 
quadrant (D4921). 
 
You asked the Plan to pre-approve localized delivery of antimicrobial agents and gingival irrigation. You say 
that these services are urgent and medically necessary. The Plan denied your request. The Plan says these 
services are not covered under your benefits. 
 
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 pre-approve 
localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per 
tooth (D4381) and gingival irrigation  per quadrant (D4921).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are a fall risk and are not able to get out of bed 
on your own. You say you live on your own and will have to be able to care for yourself before you return 
home. You feel physical therapy will help you to return home. The Plan denied your request. The Plan says you 
do not meet Medicare criteria for SNF care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have documented skilled nursing or skilled therapy needs.  Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 special power wheelchair and accessories 
(K0856, E0953, E0955, E0956, E1002, E1012, E1028, E2311, E2361, E2603, E2620). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee has a history 
of lumbar laminectomy and has a recent diagnosis of Parkinson's. His mobility has been deteriorating over the 
past year. The requested wheelchair is medically necessary for the enrollee's condition. The Plan denied your 
request. The Plan says the enrollee does not meet coverage criteria for the requested wheelchair and 
accessories. Some accessories do not serve a medical purpose and are not covered. The wheelchair is medically 
necessary for individuals that require power tilt and power recline. The notes do not show the enrollee needs 
either of these options. The upgraded electronics (electronic connector to 2 power options) are not medically 
necessary. Notes do not show that the enrollee needs power leg lifts. 
 
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 the enrollee has a 
neurologic disorder with functional deficits. Criteria for a power wheelchair are met but not for the specifically 
requested power wheelchair. The documentation does not indicate that the enrollee has any pressure injuries or 
requires intermittent catheterization of the bladder that would necessitate power tilt or recline. The requested 
electrical accessories are not medically necessary as the enrollee does have use of the upper extremity and can 
operate and control the power options using the switches that are included in the basic wheelchair. 
 
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 group 3 special power wheelchair and accessories (K0856, E0953, 
E0955, E0956, E1002, E1012, E1028, E2311, E2361, E2603, E2620).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for you. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that you have morbid obesity and osteoarthritis. The 
record indicates that you also have a stage I pressure ulcer and that you are independent of feeding. The record 
indicates that the upper extremity strength is 3/5. The record does not support that you are unable to control the 
three power options with their own switches. 
 
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 expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a socket for a lower limb prosthesis (L5999). 
 
You asked the Plan to pre-approve the socket. You say that this feature is medically necessary. The Plan denied 
your request. The Plan says socket features cannot be billed separately using code L5999. 
 
The Plan must follow Medicare rules. Medicare rules say that code L5999 must not be used for any features or 
functions of a socket. 
 
We looked at the file and Medicare rules. The request is for a socket. Socket features billed using code L5999 
is unbundling and incorrect coding. Based on this information, we decided that Medicare rules for coverage of 
the socket have not been met. Therefore, we decided that the Plan does not have to pre-approve a socket for a 
lower limb prosthesis (L5999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair. 
 
You asked the Plan to pre-approve a group 2 power wheelchair. 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 follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria 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 group 2 power wheelchair. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
indicates the the enrollee has a mobility deficit that impairs mobility related activities of daily living 
(MRADLs) in the home and is not ameliorated by a walker, cane, manual wheelchair due weakness, pain, falls, 
poor endurance. The documentation is conflicting on whether the enrollee has a wheelchair or now. The 
November 28, 2022 appeal states she has no wheelchair. The September 13, 2022 document notes she has a 
manual wheelchair. Furthermore, the documentation also indicates on prior review that a K0823 was delivered 
on November 11, 2022. Furthermore, the documentation notes that the enrollee has had suicidal thoughts and is 
homebound due to cognitive and mobility issues therefore it is not fully clear that she has the cognitive ability 
to safely use the requested wheelchair. Given the conflicting documentation the requested Group 2 power 
wheelchair is not medically necessary per LCD L33789 and per Social Security Act, Section 1862 (a)1(A) and 
the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are not reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 
member. 
 
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 group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 2 power wheelchair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need rehabilitation services to recover. The Plan 
denied your request. The Plan says the denial of authorization for SNF care is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514). 
 
You asked the Plan to pre-approve the surgical service. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PVA is not covered when fracture is present. 
 
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 surgical service. Our reviewer says 
that the requested surgical service is not medically necessary. Our physician reviewer found the provided 
imaging indicates a fracture. The reviewer found that this is a contraindication to coverage. Therefore, the 
reviewer found that the requested surgical service is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous vertebral augmentation (22514).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic component (E2310). 
 
You asked the Plan to pre-approve an electronic component (E2310). You say that the requested electronic 
component (E2310) is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested electronic component (E2310). 
 
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 electronic component (E2310). Our 
reviewer says that the enrollee does not meet criteria for the requested electronic component (E2310). Our physician reviewer found the electronic component codes as E2310 is not medically necessary per Local 
Coverage Article (LCA): Wheelchair Options/Accessories (A52504). The documentation does not reveal that 
the enrollee requires this component to operate the wheelchair. The enrollee's strength in the right upper limb is 
sufficient to be able to control any power option using its own switch. 
 
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 electronic component (E2310) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic component (E2310).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of SNF care is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device, 
four or more leads, for multiple nerve stimulation (E0730) provided May 28, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the prescribing physician recommends an 
extended lifetime use of equipment as they are diagnosed with chronic pain and compromised mobility without 
the option for surgical correction. The Plan denied your request. The Plan says evidence of misrepresented 
services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the documentation submitted did not include the 
roof of delivery or the delivery ticket. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation 
(E0730) provided May 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman G3R Interspinous device. 
 
You asked the Plan to pre-approve the Minuteman G3R Interspinous device. You say that the requested 
Minuteman G3R Interspinous device is medically necessary. The Plan denied your request. The Plan says the 
requested Minuteman G3R Interspinous device is not medically necessary. 
 
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 Minuteman G3R Interspinous 
device. Our reviewer says that the requested Minuteman G3R Interspinous device is not medically necessary. 
Our physician reviewer found the Minuteman device is experimental, and more research is needed. 
 
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 Minuteman G3R Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Minuteman G3R Interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Transcutaneous electrical nerve stimulation device (E0730) 
provided on June 7, 2022. 
 
You asked the Plan to pay for the nerve stimulation device. You say that this device was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a Transcutaneous electrical nerve stimulation device (E0730) 
provided on June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the requested ventilator is to be used for the 
treatment of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator 
set in AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 ventilator. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of COPD, but 
there are no pulmonary function tests to confirm and assess severity. There is a history of chronically elevated 
hemidiaphragm. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. The enrollee 
was recently admitted with NSTEMI. ABGs at different times showed PaCO2 as low as 30 and as high as 59. There is no ABG done while stable to determine whether there is chronic CO2 retention. If the enrollee does 
have severe COPD and chronic CO2 retention, may benefit from BiPAP with AVAPS during sleep. Medicare 
does not cover a home ventilator when used as 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).