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

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies identified 
with codes A9278 and A9276. 
 
You asked the Plan to pre-approve continuous glucose monitor (CGM) supplies. You say that you have been 
on insulin for 10 years and test yourself four times a day. The Plan denied your request. The Plan says the 
requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).    
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of continuous glucose monitor (CGM) supplies have not been met. Specifically, the requested CGM 
device does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by 
Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve continuous glucose 
monitor (CGM) supplies identified with codes A9278 and A9276.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that you strongly urge for reconsideration and 
approving of the authorization. Without non-invasive ventilation (NIV) therapy, this enrollee is at high risk for 
hospital readmission and potentially life-threatening exacerbation. The Plan denied your request. The Plan says 
the noninvasive ventilator requested 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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records in this case document a diagnosis of chronic respiratory failure consequent 
to chronic obstructive pulmonary disease. The provided records document that the home ventilator is being 
requested for use in targeted tidal volume - volume assured pressure support (TTV-VAPS) mode with auto-
EPAP (AE) which could be provided by a BiPap device with average volume assured pressure support 
(AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPap device with 
AVAPS and a back-up rate. The records state the enrollee "continues to tolerate BiPap at night and as needed 
during the day with naps." 
 
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 home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat lift mechanism, electric, any type (E0627). 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that after having a total knee replacement, 
you still have trouble with your leg. 
 The Plan denied your request. The Plan says the criteria for coverage has not been met. 
 
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 the seat lift mechanism. 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 total knee replacement. This is evidence of severe knee arthritis, 
but it has been treated. Severe arthritis is not present in that knee. No other diagnosis of arthritis of hip or knee 
is recorded in the record. The enrollee is not fully incapable of rising from a chair as the prescription states. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the seat lift mechanism, electric, any type (E0627).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one home physician visit. 
 
You asked the Plan to pre-approve one home physician visit. You say that one home physician visit is 
medically necessary. The Plan denied your request. The Plan says the requested home physician visit is not 
medically necessary. The notes do not support a home-bound status. 
 
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 one home physician visit. Our reviewer 
says that the requested home physician visit is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no documentation provided indicating that the enrollee is unable to leave 
his residence for physician visits. The review has determined that the requested home physician visit at issue 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 one home physician visit have not been met. Therefore, we decided that the 
Plan does not have to pre-approve one home physician visit.
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 enrollee needs this device. The Plan 
denied your request. The Plan says under Medicare guidelines, your request is not medically necessary because 
your records show you that the ordered settings for the noninvasive ventilator can be delivered by a bilevel 
positive airway pressure (BiPAP) machine with average volume-assured pressure support (AVAPS) capability. 
 
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 chronic obstructive pulmonary disease (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 that in this case, the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record 
indicates that the enrollee was successfully treated with BiPAP in the hospital. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The Plan has indicated 
coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1971) foot, plastic, silicone or 
equal, heel stabilizer, prefabricated, off-the-shelf, each (L3170) addition to lower extremity, pelvic control, hip 
joint, adjustable flexion, extension, abduction control, each (L2624) and prefabricated Hip Abduction Orthosis 
(L1686) provided November 23, 2021, to November 24, 2021. 
 
You asked the Plan to pay for the orthoses. You say that attached are the medical records requested to process 
claims. Please reprocess the claim. The Plan denied your request. The Plan says information is needed to 
consider this charge. 
 
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 pay for the orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no clinicals supporting this request. The physician notes do not include a 
musculoskeletal exam and there are no notes from any other clinicians. The records supplied do not support the 
request 
 
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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for the ankle foot orthosis (L1971) foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-
the-shelf, each (L3170) addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, 
abduction control, each (L2624) and prefabricated Hip Abduction Orthosis (L1686) provided November 23, 
2021, to November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight portable oxygen concentrator (E1399). 
 
You asked the Plan to pre-approve the lightweight portable oxygen concentrator. You say that this item is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 lightweight portable oxygen 
concentrator Our reviewer says that the requested item is not medically necessary. Our physician reviewer 
found the provided records in this case recommend a lighter portable oxygen concentrator so that she would be 
compliant with its use but do not document that the requested device is medically necessary as opposed to a 
standard portable oxygen concentrator. The requested item is considered a deluxe item and is not eligible for 
coverage. 
 
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 lightweight portable oxygen concentrator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lightweight portable oxygen concentrator (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that you urgently require this item. The Plan 
denied your request. The Plan says a home ventilator is not medically necessary because your needs can be met 
with Bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) 
capabilities. 
 
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 a home ventilator is not medically necessary for you. Our physician reviewer found you have chronic 
obstructive pulmonary disease (COPD) on oxygen and were recently hospitalized with pneumonia. Arterial 
blood gas (ABG) showed acute on chronic hypercarbic respiratory failure. You improved with antibiotics and 
BiPAP along with other treatments. There are no pulmonary function tests assessing the severity of the 
COPD. There is no ABG done while stable, after resolution of the pneumonia, to document chronic CO2 
retention. There is no consideration of obstructive sleep apnea or obesity-hypoventilation syndrome. There is 
no diagnosis of thoracic restrictive disease or neuromuscular disease. If you have chronic CO2 retention, you 
may benefit from BiPAP with AVAPS at night. Medicare does not cover a home ventilator when used at 
settings that can be provided 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (78451). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with imaging may be covered when 
reasonable and necessary for certain conditions. 
 
   
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 myocardial perfusion imaging. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has had no 
cardiovascular signs or symptoms. An echocardiogram, carotid ultrasound, transcranial doppler and lower 
extremity ultrasound imaging studies were unremarkable. There is no evidence provided that would support the 
need for radionuclide stress testing at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging (78451).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (96132, 96137, 93133, 
96136). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that this service was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the capacity to meaningfully benefit from 
psychotherapy must be documented in the medical record. 
 
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 neuropsychological testing. Our 
reviewer says that the requested service is not medically necessary. Our physician reviewer found it is unclear 
what neuropsychological testing would help in treatment changes in this patient. This patient does not meet 
criteria for neuropsychological testing as it is unclear what question is to be answered and treatment rendered. 
It is also unclear if the patient is currently suffering from depression or anxiety based on the records provided. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (96132, 96137, 93133, 96136).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivestym. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Nivestym is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee is receiving planned 
chemotherapy with Opdivo as treatment for esophageal cancer. The record does not indicate that he is receiving 
myelosuppressive chemotherapy with more than a 10 percent risk of myelosuppression. The criteria for 
coverage are not met and the Nivestym is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nivestym.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied therapy visits. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled therapy needs and the requested, home health services are not medically 
necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B coverage criteria for Prolia. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
enrollee does not meet the coverage criteria for Prolia. Our physician reviewer found the provided records do 
not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. Our reviewer also 
found that the record does not indicate that the enrollee has a contraindication to, or would have an adverse 
effect from the Plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).