Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive the needed care and therapy services. The Plan denied your request. The Plan says the 
services the enrollee needs could be provided in another setting, such as an acute rehabilitation facility, skilled 
nursing facility, nursing facility, outpatient setting or home care. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve the seat lift mechanism.. You say that the seat lift is medically necessary. 
The Plan denied your request. The Plan says that coverage criteria 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 this item is medically necessary. Our physician reviewer found the records show that the enrollee is 
unable to stand unassisted. The enrollee has the ability to walk once standing. The records show that a seat lift 
is included in the treating practitioner's course of treatment. 
 
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 been met. Therefore, we decided that the Plan has 
to pre-approve a seat lift mechanism.  
 
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 pre-approve enrollment in the Special Supplemental Benefit for the 
Chronically Ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve the SSBCI benefit. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says the criteria for enrollment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefit have not been met. Specifically, we have confirmed that you do not require 
intensive care management and are not high risk for hospitalization. Therefore, we decided that the Plan does 
not have to pre-approve enrollment in the Special Supplemental Benefit for the Chronically Ill (SSBCI) benefit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) Upper Extremity 
(Right Shoulder) without Contrast (73221). 
 
You asked the Plan to pre-approve a magnetic resonance imaging (MRI) Upper Extremity (Right Shoulder) 
without Contrast (73221). You say that the enrollee has had numerous injuries over the years, pain in the right 
shoulder and has progressed to the point now it is functionally limiting. The Plan denied your request. The Plan 
says there is no documentation of trial and failure of 6 weeks of physical therapy or any conservative 
management, medical necessity for this imaging study has not been established and the request for Magnetic 
Resonance Imaging (MRI) of the Upper Extremity Joint (Right Shoulder) without Contrast (CPT 73221) is 
upheld at this time. 
 
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 Upper Ext (Right Shoulder) 
without Contrast (73221). Our reviewer says that the service is not medically necessary. Our physician 
reviewer found the requested right shoulder MRI, in this case, is not medically reasonable or necessary, 
significant pain relief can be achieved by conservative therapy such as analgesia, manual therapy and 
physiotherapeutic exercises and leads to improvements in the active range of motion. 
 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 MRI Upper Ext (Right Shoulder) without Contrast (73221) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) Upper 
Extremity (Right Shoulder) without Contrast (73221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0676). 
 
You asked the Plan to pre-approve an intermittent limb compression device. 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 claims for E0676 will be statutorily denied as no 
Medicare benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an intermittent limb compression device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intermittent limb compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis continuous glucose monitor (CGM) 
transmitter. 
 
You asked the Plan to pre-approve a Dexcom G6 CGM transmitter. You say that the enrollee is diagnosed with 
type 2 diabetes and needs the requested device. The Plan denied your request. The Plan says the records show 
the enrollee is not on insulin. A CGM is not covered under Medicare if the enrollee is not on insulin. 
 
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 Dexcom 
G6 CGM transmitter have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 Mis continuous glucose monitor (CGM) transmitter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefit for the chronically ill 
(SSBCI) coverage. 
 
You asked the Plan to pre-approve the SSBCI coverage. You say that the records provided support the need for 
SSBCI coverage. The Plan denied your request. The Plan says there is no documentation supporting that the 
criteria for SSBCI coverage have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
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 SSBCI coverage. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found that the enrollee is a male with 
back and neck pain, hip osteoarthritis, chronic pain, spina bifida occulta, lumbar spondylosis, and 
radiculopathy. Our physician reviewer has tried multiple treatments including medications and injections but is 
not a candidate for surgery. There is insufficient evidence found describing the enrollee meeting all of the 
requirements for SSBCI. Although the enrollee has a condition that limits their overall function, the enrollee 
does not appear to require intensive care management nor have a high risk for hospitalization.   
We looked at this physicians review, the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SSBCI coverage have not been met. Specifically, we have confirmed that 
you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that 
the Plan does not have to pre-approve special supplemental benefit for the chronically ill (SSBCI) coverage.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective catheter placement (procedure code 36247) 
rendered on June 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support the separate reporting of CPT 36247. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 36247 is "Selective catheter placement, arterial system; 
initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular 
family." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not support the procedure code 36247 as it was included in the performed procedure codes 37229 and 37225. 
Based on coding guidelines this procedure code would need to show it was separate from the primary 
procedure code and that information was not included within the operative note. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for selective catheter placement (procedure code 36247) rendered on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA disc NP device. 
 
You asked the Plan to pre-approve a VIA disc NP device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 VIA disc NP device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the VIA disc NP device is experimental for back pain. 
 
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 VIA disc NP device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a VIA disc NP device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Stabilink procedure (22612, 22899). 
 
You asked the Plan to pre-approve the Stabilink procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Stabilink procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the peer-reviewed published medical literature to 
support the long-term clinical benefit of interspinous process fixation devices such as the Stabilink procedure. 
 
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 Stabilink procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Stabilink procedure (22612, 22899).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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 the home ventilator. You say that this device 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 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 the home ventilator. Our reviewer says 
that the requested device is not medically necessary. Our physician reviewer found the Life2000 device is not a 
true ventilator, because it is not capable of providing full ventilatory support. Its primary intended use is during 
activity, and not to treat chronic CO2 retention during sleep. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee's condition has not stabilized and 
requires further skilled nursing care. The Plan denied your request. The Plan says skilled nursing facility 
services are no longer required. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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 continued skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need continued care due to a wound currently 
being treated. The Plan denied your request. The Plan says you no longer require daily skilled care to meet your 
needs. 
 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 the enrollee was admitted to the hospital with cellulitis on February 11, 2023. She 
was discharged to a SNF for skill therapy and nursing services. As of the date when continued services were 
denied, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented 
skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs can, as a practical matter, 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 continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the enrollee 
was provided an E0651 previously in 2019. The enrollee has been utilizing the device and still has significant 
swelling. You have submitted medical records to support medical necessity. The Plan denied your request. The 
Plan says records do not show the enrollee meets all the requirements. The request is not medically necessary 
because the enrollee does not have any swelling of the trunk and/or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).